This will get some "backs" up

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The BBC are reporting:
Back treatment 'has no benefit'

 

Its the same with every profession whose members use one modality for the wide spectrum of conditions that present. If you are a 'one-trick pony', well your bedside manner better be good, and your marketing double so.

Musculo-skeletal practitioners should have a few options to throw at things. To generalise, physiotherapists in Australia are playing the 'strength/control' card with most back pain. Chiropractors, have played the manipulation card, that they perform so well. Pods, I guess are making sure that every device pushes medial to the STJ axis and plantar-flexes the first ray...

This article throws cold water on Chiropractic manipulation. Well I have no doubt that some stiff spinal facet joints could well do with an end-range thrust. As always it is about picking your patient and your condition. I don't think that we do that, and I don't think the research addresses this either.

 

Edzard Ernst from the University of Exeter and Alan Breen from the Anglo-European College of Chiropractors discuss the practice of spine manipulation and the findings of the research.

BBC Radio 4 Today Programme. http://www.bbc.co.uk/radio4/today/listenagain/index.shtml

via the web or podcast.

Also

http://www.timesonline.co.uk/article/0,,2-2097779,00.html

 

re oh dear

Dear All,

On the radio today was Professor Ernst and Michael Van Stratten and it was a good dust up between the Researcher and the way the research was carried out and its specific findings. With much protestations from Mr Van Stratten about anecdotal evidence and he knows that pts get better.

I believe physios have the best evidence for the tt of back pain and that is a 3 part program:

Exercise Exercise Exercise.

This improves musculature range of movement and posture. Dont forget a nice pair of insoles too (just joking).

Seriously most musculo skeletal problems require the PT to do many things.

Improve fitness, lose weight , become more active, eat well.etc etc

Trouble is is that a pt wants soemone else to take their money and prod and poke them using machines that got beep. So no active pt involvement in their own tt.

rant over.

Oh yes appologies i forgot the MAGIC WORD HOLISTIC a thousand appologies to you all.

regards David

 

There is a link to the audio on the top of the right column of this page:
http://news.bbc.co.uk/1/hi/health/4824594.stm

There is a whole body of literature about the defence mechanisms used when the evidence shows the opposite of what is beleived. We see it happening in the response to this issue and we came across elements of it in the thread here on shockwave therapy.....if anything it is entertaining to watch

 

Lets throw this into the mix:

From Medscape (free registraion required)
Multidisciplinary Group Rehabilitation Versus Individual Physiotherapy for Chronic Nonspecific Low Back Pain
A Randomized Trial

Full article (free registration required)

 

Perhaps this is so,however,we podiatrists should not be too quick to gloat here.After all,I am sure that a paper will be published throwing cold water on some mainstays of podiatric treatment(i.e. nail debridement).I do not look down at chiropractors as they do some good things.Like in any other field,there are good and bad.

 

Although my experience with statistaic is limited I have found the problem with research is the errors and limitations associated with data collection, processing and analysis which can lead to outcomes which go against common sense, or popular perception or other published research. Research can rarely be 100% conclusive because of these limitations, especially of time, money, logistics, technology, will, ethics.
A simple example
I recently read a young ladies O level research project looking at the corelation between number of driving lessons and failure rates/driving test errors, which although not finished, suggested that the data showed more lessons do not give fewer mistakes or higher pass rates. Obviously this is totally against common sense but her limitations of research obviuosly lead to large errors. Her protocol only allowed her to analyse at 50 out of 250 sets of data provided and each subject had between 3 and 10 lessons and test were carried out on different days by different examiners.

On a personal level relating to back injury. An extremely painful back injury which the NHS could do nothing for, over several months, was resolved in one treatment by a private practitioner using vigorous manipulation.

This is another fault with so called evidence based treatment it makes conclusions about expected outcomes for large groups but not individuals. This may be useful as a guide for the financial managment of clinical procedures but not as a guide to whatis best for the presenting patient.

This might be simmilar to shoe stockist finding that it is financialy more prudent to only stock a range of popular sizes. Which may mean lower prices and higher profit margins but what about the poor guy with size 13/50 feet.

Just my opinion Cheers Dave

 

This seems so obvious - but here goes.

Whether or not chiropractic technique works, can the research conclusions of a competitor in the back-health market really be taken seriously?

 

The full text of the article posted in message one is now available as a pdf file:
http://www.rsm.ac.uk/media/pdf/j06-04spinalmanip.pdf

 

BackCare UK Responds To Daily Mail Article Saying Chiropractors Are A Waste Of Time

Press release:
BackCare UK Responds To Daily Mail Article Saying Chiropractors Are A Waste Of Time

From Medical News Today

 

The osteopaths have now weighed in

Press Release
General Osteopathic Council Refutes Statement That Spinal Manipulation Does Not Work

From Medical News Today

 

Now the Americans weigh in

Controversial British study causes uproar among DCs

Chiropractic Economics

 

Ladies and Gentleman,

Although this is an old thread, I felt that as a practicing Doctor of Chiropractic that a response to this “selective literature review” is necessary.

After reading literally hundreds of these studies over the years, I becomes apparent that many are biased and not randomized, double-blinded, controlled studies. The most negative tend to be cherry picked reviews of poorly conceived trials and bear no merit.

To our credit as chiropractors there are a number of excellent, peer-reviewed, independent clinical trials conducted by respected researchers that completely refute the findings of this particular study and present compelling evidence of the efficacy of chiropractic care contrary to what this review purports.

I will summarize a few of these landmark studies and provide article citations:

1. Acute Low Back Problems in Adults. Clinical Practice Guidelines. Bigos S, et al. Agency for Health Care Policy and Research Publication No. 950642 (U.S. Department of Health and Human Services) -1994.

The following conclusions were made in this landmark study:

* Conservative treatment such as spinal manipulation should be pursued in most before cases considering surgical intervention;
* Prescription drugs such as oral steroids, antidepressant medications and colchicine are not recommended for acute low back problems.

Other interesting finds included:
# The risk of serious complications from lumbar spinal manipulation is rare;
# There is currently no evidence supporting the use of trigger point, ligamentous and facet injections, needle acupuncture or dry needling as treatment for acute back problems;
# The panel found no evidence of benefit from the application of physical agents and modalities such as ice, heat, massage, traction, ultrasound, cutaneous laser treatment, transcutaneous electrical nerve stimulation (T.E.N.S.) and biofeedback techniques.

2. The Appropriateness of Spinal Manipulation for Lower Back Pain. Shekelle PG, et al. RAND Corporation, Santa Monica, California - 1992.

Findings:

This study, conducted by the prestigious RAND Corporation, marks the first time representatives of the U.S. medical community have gone on record stating that chiropractic is an appropriate treatment for certain low back pain conditions. A second, all-chiropractic panel's ratings show agreement with the multidisciplinary panel that spinal manipulation is appropriate for specific kinds of low back pain.

3. The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain. Pran Manga and Associates. University of Ottawa, Canada - 1993.

The Canadian Government report concluded with the following findings:

• On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for low back pain. Many medical therapies are of questionable validity or are clearly inadequate;
• There is no clinical or case-control study that demonstrates or even implies that chiropractic spinal manipulation is unsafe in the treatment of low back pain. Some medical treatments are equally safe, but others are unsafe and generate iatrogenic (doctor-induced) complications for low back pain patients. Our reading of the literature suggests that chiropractic manipulation is safer than medical management of low back pain;
• Indeed, several existing medical therapies of low back pain are generally contraindicated on the basis of the existing clinical trials. There is also some evidence in the literature to suggest that spinal manipulations are less safe and less effective when performed by nonchiropractic professionals;
• There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management;
• There would be highly significant cost savings if more management of low back pain was transferred from physicians to chiropractors. Evidence from Canada and other countries suggests potential savings of many hundreds of millions annually;
• Workers' compensation studies report that injured workers with the same specific diagnosis of low back pain returned to work much sooner when treated by chiropractors than by medical physicians;
• There is good empirical evidence that patients are very satisfied with chiropractic management of low back pain and considerably less satisfied with medical physician management;
• The use of chiropractic has grown steadily over the years and chiropractors are now accepted as a legitimate healing profession by the public and an increasing number of medical physicians;
• In our view, the following offers an overwhelming case in favor of much greater use of chiropractic services in the management of low back pain:
o the effectiveness and cost effectiveness of chiropractic management of low back pain
o the untested, questionable or harmful nature of many current medical therapies
o the economic efficiency of chiropractic care for low back pain compared with medical care
o the safety of chiropractic care
o the higher satisfaction levels expressed by patients of chiropractors.
Due to serious financial problems with the Canadian governments, the different types of treatments for low back conditions were evaluated in an effort to reduce and contain health care costs. Their findings showed chiropractic manipulation was the most cost effective and efficacious care for low back pain.

(* it is no coincidence that in this decade there was one case of vertebral artery dissection and subsequent mortality attributed to chiropractic manipulation in Canada that sparked a huge battle between the medical establishment and the chiropractic profession. One of their suggestions was the inclusion of chiropractic privileges in Canadian hospitals. Obviously this did not sit well with the medical establishment and the fight to destroy the image of chiropractic began. It mirrors similar litigation in Wilk, et. Al vs. the AMA in this country where the chiropractic profession prevailed in proving that the AMA conspired to contain, control and eliminate the practice of chiropractic.

In the ensuing melee Dr. Scott Haldeman, a medical physician AND a chiropractor investigated and his findings were thus:

http://www.cmaj.ca/cgi/content/full/165/7/905

There are over 4500 licensed chiropractors in Canada. The likelihood that a chiropractor will be made aware of an arterial dissection following cervical manipulation is approximately 1:8.06 million office visits, 1:5.85 million cervical manipulations, 1:1430 chiropractic practice years and 1:48 chiropractic practice careers. This is significantly less than the estimates of 1:500 000–1 million cervical manipulations calculated from surveys of neurologists.7,8,9 These data also confirm the conclusions of a recent review of the literature in which patients at risk for this complication could not be identified.10

4. Chiropractic Evaluation Study Task III Report of the Relevant Literature. MRI Project No. 8533-D. MacDonald MJ, Morton L. For Department of Defense, OCHAMPUS, Aurora, Colorado - 1986.


This study examined clinical trials published in the professional literature between 1930 and 1981.

The researchers concluded that:

* manual therapy was superior to placebos,
* there was greater mobility following manipulation,
* the duration of treatment was shorter for the manipulated groups,
* there was improved lateral flexion and rotation after manipulation,
* the numerous case studies throughout the literature report the satisfaction of chiropractic patients with the outcome of treatments.

As you can see there is another side to this coin and valid research to support the wide inclusion of chiropractic care as portal-of-entry providers specifically for low back pain. There are several more progressive hospitals in this country where DC’s enjoy privilege and I hope this trend will continue. Until then we can only ‘fight the good fight’, produce more clinical trails to present the overwhelming truth about the efficacy and safety of manipulation and raise our heads above the unfounded that bias we as a profession experience on a daily basis from the allopathic profession.

In closing I have a response to the authors comment about the potential risk to benefit of manipulation. Of course there are minimal risks of minor insult involved in the practice of chiropractic and there are rare occurrences of more severe outcomes in the literature. We do not deny that. If there is a risk of grave iatrogenic injury from manipulation as delivered by Doctors of Chiropractic, why is my 1 million/ 3 million malpractice insurance policy premium renewed at a current rate of about $1,200 per annum?

Could the answer to the outcome of this literature review be professional economics and territorial perseverance?

Lastly I thank David for this keen observation:

 

In fairness, the report stated that there was little evidence for the effectiveness of spinal manipulation for any condition EXCEPT back pain. The studies which you list are concerned with (lower) back pain and not period pain, colic, asthma and dizziness which were part of the study. I don't have any axe to grind and I am sure you are correct concerning your second last paragraph. However, it is entirely possible that the individual concerned was misdiagnosed in the NHS and this does nothing whatever to justify your damning statement on evidence based treatment.

All the best

Bill Liggins

 

Bill,

Perhaps I should have been more precise. I do understand what you are saying and I agree mostly with your assessment. I am not in any way damning evidence based treatment, to the contrary and the chagrin of many of my colleagues, I endorse and practice it.

The article does discuss period pain, colic pain asthma and dizziness. They also reference neck and back pain or I would not have responded at all. I would like to point out that typically studies such as these that I believe contain a significant bias often quote studies that blend pain syndromes from a non-mechanical etiology with mechanical neck and low back pain and this is imprecise.

"It was found the data did not show spinal manipulation was effective for any condition - except for back pain where it is superior to sham manipulation, but not better than conventional treatments."

This is what you commented on and I was merely refuting what I believe is a flawed statement based on poor design of the review and the lack of focus directed at mechanical pain syndromes by including the above and then referencing neck and back pain. Does this seem somewhat illogical to anyone else reading this?

If the researchers include organic pain syndromes and then reference neck and low back pain, ignoring precision as to whether it is mechanical or otherwise and then damn spinal manipulation for all of the above they should be criticized. In light of much better research available refuting their broad claims I feel justified in commenting.

“Professor Edzard Ernst, who led the review, said: "There is little evidence that spinal manipulation is effective in the treatment of any medical condition.”

This is a very vague and misleading conclusion in my humble opinion. I would consider mechanical low back or neck pain to be a medical condition necessitating appropriate medical care. The fact that chiropractors are not medical doctors is semantic here; we provide a service that is often referred to as manual medicine here in the U.S. but scorned because we are not medical providers. All health insurers base payment for these services on “medically necessary care to cure or relieve” the condition diagnosed.

The problem with this review is they are comparing apples to oranges and then mixing the two together to arrive at a conclusion that does not adequately controvert the more qualified and accepted studies.

This review is all over the map.

I hope that you will find some agreement with what I have said here Bill.

Regards,