Update on Singh "bogus chiropractics" story

June 10, 2009 8:22 PM

An update regarding the Singh vs. British Chiropractic Association lawsuit is available here.

In the linked article we learn that UK chiropractics are being told by their association to remove "any claims for treatment that cannot be substantiated with chiropractic research" from their websites or, preferably, to just get rid of their websites entirely.

It is a few days too late to update the original thread here, in which we learned that the chiropractic society had successfully won a case against Simon Singh, an author of layman's science books who stated that some chiropractic claims are "bogus."

It appears that a public science movement that has started to campaign in support of Singh is having some success in forcing chiropracters to not make bogus claims. Simon Singh has a posse.

posted by five fresh fish to MetaFilter-Related at 8:22 PM (58 comments total)

That leaked email on the page your first link goes to looks like sufficient evidence on its own to defend Singh's case, even accepting the judge's bogus interpretation of the word 'bogus'!
posted by nowonmai at 8:46 PM on June 10, 2009

Thanks for the update. I do think that there is a slowly-building backlash against psuedoscience- I hope it has enough momentum to become something meaningful rather than petering out.
posted by Pope Guilty at 9:22 PM on June 10, 2009

Simon Singh made an appearance on the most recent Skeptics' Guide to the Universe podcast.
posted by Stylus Happenstance at 3:49 AM on June 11, 2009

"Chiropractic research" is an oxymoron.
posted by fourcheesemac at 4:29 AM on June 11, 2009 [1 favorite]

"Chiropractic research" is an oxymoron.

Bullshit. I realize there are a lot of crackpots who are also chiropractors, but the fact is that for back pain it does actually work.
posted by delmoi at 6:19 AM on June 11, 2009 [1 favorite]

Sign the statement.
posted by Dumsnill at 6:39 AM on June 11, 2009

"The fact is" is an assertion, not evidence. "It actually does work" is a statement of anecdotal opinion, not proof. Lots of things "work" for pain; to the extent that chiropractic manipulation contains elements of massage therapy, I'm sure some people leave the office feeling better (those who don't leave paralyzed from a spinal cord injury).

There is no legitimate body of science for "chiropractice." What there is is, like all alt med bullshit, alt med bullshit. The theory of pathogenesis at the root of chiropractic is patently false. Chiropractic education is a pathetic joke and schools of chiropractic attract the weakest students as applicants.

It's a cult. Of course it has true believers. Doesn't mean it isn't bullshit.

Put up the science and we can have the argument. And don't put up the pseudoscience. Put up the peer-reviewed science.
posted by fourcheesemac at 6:41 AM on June 11, 2009 [18 favorites]

The problem here is that people think of two different things when discussing chiropracty. The complete bullshit "by manipulating your spine I will cure your acne!" aspect of it or the actually useful "I'm a masseuse/APT practitioner/PT" part.

The former will try to sell you on homeopathy and crystals, the latter usually calls themselves sports chiropractors or markets themselves to office workers with bad posture.
posted by Loto at 7:15 AM on June 11, 2009

By APT I meant ATP...
posted by Loto at 7:17 AM on June 11, 2009

Re: chiropractic treatment for back pain. Focusing only on the most legitimate claims of chiropractic therapy (i.e., the treatment of back pain), the evidence is neutral at best and generally negative:

The best randomized study (the UCLA study) found no substantial short-term benefit: "Physical modalities used by chiropractors in this managed-care organization did not appear to be effective in the treatment of patients with LBP, although a small short-term benefit for some patients cannot be ruled out."

Follow-on analysis found that the small short-term benefit is probably the result of patient satisfaction, which is in turn the result of the tendency of chiropractors to communicate better than doctors: "Communication of advice and information to patients with low back pain increases their satisfaction with providers and accounts for much of the difference between chiropractic and medical patients' satisfaction." and "Patient satisfaction may confer small short-term clinical benefits for low back pain patients. Long-term perceived improvement may reflect, in part, perceived past improvement as measured by satisfaction."

At 6 months and 18 months, chiropractic treatment seemed to be about as effective as medical treatment or physical therapy: "After 6 months of follow-up, chiropractic care and medical care for low back pain were comparable in their effectiveness." And at 18 months "[d]ifferences in outcomes between medical and chiropractic care without physical therapy or modalities are not clinically meaningful, although chiropractic may result in a greater likelihood of perceived improvement, perhaps reflecting satisfaction or lack of blinding."

That was a randomized trial. What if patients are better at choosing whether chiropractic therapy or medical therapy is right for them? Turns out it doesn't improve outcomes or reduce costs: "A model of care that offered access to a choice of complementary and alternative medicine therapies for acute LBP did not result in clinically significant improvements in symptom relief or functional restoration. This model was associated with greater patient satisfaction but increased total costs."

Overall, recent reviews of the literature suggest that the small, uncertain benefits of chiropractic therapy do not outweigh the risks and costs, especially given that the medical alternative rests on much stronger scientific ground: "With the possible exception of back pain, chiropractic spinal manipulation has not been shown to be effective for any medical condition. Manipulation is associated with frequent mild adverse effects and with serious complications of unknown incidence. Its cost-effectiveness has not been demonstrated beyond reasonable doubt. The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt."

Those studies that suggest chiropractic therapy is beneficial are severely compromised by bias: "This indicates an association between authorship by osteopaths or chiropractors and low methodological quality and positive conclusion. We conclude that the outcomes of reviews of this subject are strongly influenced by both scientific rigour and profession of authors. The effectiveness of spinal manipulation for back pain is less certain than many reviews suggest; most high quality reviews reach negative conclusions."
posted by jedicus at 7:35 AM on June 11, 2009 [25 favorites]

Chiropracters are the biggest propagaters of bullshit I have ever seen, and I say that as someone that endorses any and all approaches to back pain. Some of the ridiculous shit that comes out of patient's mouths when they recount what goes on there is like something a five-year old would imagine if you asked them how to build an airplane. Their industry is so badly managed as far as policing that it is a wonder that the few, actual legitimate chiros who do basic hands on work and who also endorse exercise and stretching don't form their own discipline.
posted by docpops at 7:37 AM on June 11, 2009 [1 favorite]

"The fact is" is an assertion, not evidence. "It actually does work" is a statement of anecdotal opinion, not proof.

That's true, now let's look at your comment:

"Chiropractic research" is an oxymoron.

Looks like an evidence free assertion It would be nice if you held yourself to the same standards you hold others, but I realize that's asking a lot for most people.

Re: chiropractic treatment for back pain. Focusing only on the most legitimate claims of chiropractic therapy (i.e., the treatment of back pain), the evidence is neutral at best and generally negative:

The "most legitimate" claim? It's also pretty much the only major claim and it's what the vast majority of chiropractic care is for. Secondly, look at the evidence you actually cited:

At 6 months and 18 months, chiropractic treatment seemed to be about as effective as medical treatment or physical therapy: "After 6 months of follow-up, chiropractic care and medical care for low back pain were comparable in their effectiveness."

Okay, so your own study says that it's as effective as medical care. How is that evidence that it doesn't work? Let me repeat that: as effective as medical care. But keep in mind that medical care for back problems means surgery, and that is certainly not without risk.

I never said that Chiropractic care would produce instant results, only that it worked for back pain. And here you've shown that it does work for back pain, just as well as traditional medical. It's also a lot cheaper, which isn't exactly a non-concern here in the U.S.

Anyway, the point is: You've proven that chiropractic care works as well as ordinary medical care and physical therapy, which is the exact opposite of what fourcheesemac was saying.

Put up the science and we can have the argument. And don't put up the pseudoscience. Put up the peer-reviewed science.

Doesn't look like I need too since jedicus already has. Despite framing his comment in a negative light, he's actually shown that it works as well as regular medical care over the long term.

It would be nice if they dropped some of the ridiculous bullshit, and I certainly don't think they should be claiming that they can fix problems beyond back pain, but for that, it works.
posted by delmoi at 8:35 AM on June 11, 2009 [2 favorites]

Also, here are some other studies:

Inconsistent Grading of Evidence Across Countries: A Review of Low Back Pain Guidelines in the Journal of Manipulative and Physiological Therapeutics is a review of various spinal manipulation techniques and found them effective, but that standards for measuring effectiveness were inconsistent. Here is a summary of one of the studies looked at:

After 6 mo of follow-up, both medical care and chiropractic care for LBP were comparable in effectiveness. Physical therapy may be marginally more effective than medical care alone for reducing disability in some patients, but possible benefits were small.

Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. apparently concluded that Chiropractic care worked well, but it's behind a pay wall.

There's also: Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis.

CONCLUSIONS: As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.

Another article: Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. which was published in the Annals of internal medicine

CONCLUSIONS: Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation. For acute low back pain, the only therapy with good evidence of efficacy is superficial heat.

(note that acute would mean short term pain while chronic means long term pain)

That chiropractic care works for lower back pain isn't even a controversial statement as far as I know, it just seems that random people on the internet seem to think it is because many chiropractors have various crackpot beliefs. But it seems like (by looking through these studies) that Spinal Manipulation Therapy is starting to be used and studied by other people besides chiropractors, which good since it works.
posted by delmoi at 9:08 AM on June 11, 2009

I started having back pain in high school, and got little to no help from my primary care physician. My insurance covered chiropractics, which involved back manipulation and stretching exercises. At the very least, it alleviated the pain, and (having had back pain long enough now to be able to compare it) worked as well as massage therapy, which my insurance did not cover (and no one ever mentioned actual physical therapy to me).

I realize that anecdote is not the singular of data, but in terms of efficacy and access, I'm grateful for the chiropractic care that I got.

However, I will also say that the chiropractor (who was a friend of the family) also believes a lot of horseshit about energy currents, etc. that I think is mystical hogwash, and that if I weren't pretty resolutely skeptical I may have attempted to treat other ailments with it. But hey, I've also been told patently untrue things by massage therapists, osteopaths, homeopaths and allopaths. For me, the danger of believing alternate medicine's woowoo is lower than the risk of, say, the stupid shit that traditional doctors have attempted to foist on me, though I recognize that's not the case for everyone (and at least with traditional doctors, when they recommend a course of treatment, I can assume that they're in an evidence-based paradigm and have some sort of literature that will support their claims).
posted by klangklangston at 9:29 AM on June 11, 2009

Oh and:

Put up the science and we can have the argument. And don't put up the pseudoscience. Put up the peer-reviewed science.

Now that "the science" has been put up it looks like fourcheesemac isn't interested in having an argument after all.
posted by delmoi at 9:47 AM on June 11, 2009

Now that "the science" has been put up it looks like fourcheesemac isn't interested in having an argument after all.

Oh, delmoi. Don't ever change.
posted by grouse at 9:59 AM on June 11, 2009 [2 favorites]

as effective as medical care

As effective but more expensive, per the other studies. I'd say that's a net loss.

Also, medical care doesn't necessarily mean surgery. In fact, surgery for back pain is rapidly becoming less and less popular, as more studies suggest that it's not particularly effective for simple back pain, has lots of side effects and potential complications, and is expensive (kind of like chiropractic therapy, in fact). The emerging consensus is that we're not perfectly evolved for walking upright, we're overweight, we don't get enough exercise, and a lot of people sit in chairs all day or stand with poor posture. The result is that some back pain is inevitable and probably best treated with analgesics and lifestyle changes.

Anyway, as klangklangston points out, even when chiropractic therapy is effective for an individual's back pain, it's so often combined with the nonscientific nonsense aspects that it represents a significant danger to people's wellbeing. I would favor something like docpops suggested, but absent that kind of separation between the reasonably safe and effective part and the nonsense parts, I have no trouble damning the entire profession.
posted by jedicus at 10:10 AM on June 11, 2009

Thanks for the update. I do think that there is a slowly-building backlash against psuedoscience- I hope it has enough momentum to become something meaningful rather than petering out.

The other day I was watching Planet of the Apes - I switched it on near the beginning and realized that I'd never I'd never actually seen it from the start before, and so I ended up really watching it as a movie and not as a collection of well worn hand-me-down lines and images. One of the things I noticed, along with how 70s it is and how it practically waves a sign around reading "LOOK, SOCIAL COMMENTARY" at times, is that it shows a fight between science (blimey! We've got a talking human!) and woo (The big book says humans can't talk, and anyway they are teh EVILs so cover your ears) and the science side is the side of good and (kind of) wins.

You just don't see that much in movies these days, everything is all about how woo is real and silly scientists are just crap and wrong.
posted by Artw at 10:13 AM on June 11, 2009 [3 favorites]

Meta-analysis, anyone?
posted by TedW at 10:54 AM on June 11, 2009 [2 favorites]

LOLchiropractors and the cargo cult science that "demonstrates their effectiveness."
posted by killdevil at 11:21 AM on June 11, 2009

I love Feynman.
posted by Loto at 11:32 AM on June 11, 2009

Well, the question was whether or not Spinal Manipulative Therapy (done by a chiropractor or someone else) works. And the answer is pretty clear that it does. It seems to work about as well as "standard" medical care. The people who are being un-scientific here are the ones who claim it doesn't work, which as far as I can tell is basically just fourcheesemac. And I guess killdevil here who is apparently so sure that Chiropractic care is B.S. he doesn't feel like he needs to bother responding to the articles, which are published on pubmed, (A website of the National Institutes of Health)

Frankly, the attitude is idiotic. Those who claim to be arguing for "sound science" are ignoring what the scientific studies actually say. And of course they're not even bothering actually bring cite any other research that actually backs up what they say. The only thing that people have been able to prove is that it isn't more effective then other medical care. Or that it's not cheaper.

If you have two types of therapy that overall have about the same efficacy, then it's likely that different people will respond differently to different treatments.

For example, placebo and excessive are very effective in treating depression, almost the same as taking anti-depressants. But I don't think anyone, except for Scientologists would argue that because over all they are about as effective that no one should take anti-depressants or that anti-depressants don't actually do anything.

The only citations and references that critics have been able to bring up in this thread say that chiropractic care works about as well as other therapies.

Meta-analysis, anyone?

That isn't the only meta-analysis that's ever been done, This paper which I also linked too, is a meta analysis, spanning 887 different studies. Again, this was published a peer reviewed journal and published on pubmed, which is run by the U.S. National Library of Medicine and the National Institutes of Health.

If you don't believe that that counts as "real science" then by all means tell us exactly how we can determine whether or not something is or is not "real science"
posted by delmoi at 12:15 PM on June 11, 2009

Delmoi, you were loaded for bear today. Love it whan that happens.
posted by jfuller at 12:44 PM on June 11, 2009

The only citations and references that critics have been able to bring up in this thread say that chiropractic care works about as well as other therapies.

That's a misrepresentation. There was no benefit in the short term once patient satisfaction is compensated for. As your citations point out, that leaves chronic back pain (and more specifically lower back pain) as basically the only indication for chiropractic therapy.

Also, two of your citations were published in the Journal of Manipulative and Physiological Therapeutics, the journal of the American Chiropractic Association, so it's pretty unlikely it would publish anything that called the validity of chiropractic therapy into question. Remember also the paper that found "an association between authorship by osteopaths or chiropractors and low methodological quality and positive conclusion."

Anyway, as I said, the real issues are a) it's more expensive for, at best, the same quality and b) it exposes patients to a lot of harmful nonsense.

Finally, the meta-analysis thing was a joke. We're analyzing a bunch of studies (i.e., a meta-analysis) while discussing a Metafilter thread (i.e., a Meta-analysis).
posted by jedicus at 12:47 PM on June 11, 2009 [1 favorite]

As your citations point out, that leaves chronic back pain (and more specifically lower back pain) as basically the only indication for chiropractic therapy.

Which is fine. I'm pretty sure that lower back pain is what the vast majority of people go to chiropractic care providers for.

Anyway, as I said, the real issues are a) it's more expensive for, at best, the same quality and b) it exposes patients to a lot of harmful nonsense.

I realize that there are crackpot chiropractors, but it would be interesting to see how many of them actually push that kind of stuff. There are also crackpot MDs, like the Atkins Diet guy, those doctors who push bio identical hormone therapy, and so on.

It would be best if the same kinds of therapies could be done by "real" doctors or physical therapists rather then people who more likely to be all crackpottish.
posted by delmoi at 2:00 PM on June 11, 2009

which are published on PubMed, (A website of the National Institutes of Health)

There are many, many thousands of studies available via PubMed whose content is scientifically suspect. Getting an article published, even in a reputable journal, is no guarantee as to the quality of the research it reports on. I mean, this guy got 28 totally fraudulent papers published in Nature, Science and Physical Review. If your research is sexy, and particularly if it purports to upend traditional thinking in its topic area, it's not terribly hard to get your articles into prestigious pubs.

Finally, the meta-analysis thing was a joke. We're analyzing a bunch of studies (i.e., a meta-analysis) while discussing a Metafilter thread (i.e., a Meta-analysis).

I dunno, I've done some meta-analysis work, and the epidemiologists I worked with were incredibly rigorous in the way they went about integrating the results of multiple studies. There's a lot of statistics theory that underlies good meta-analysis, and done well (and I'm not suggesting it was done well in this case), it can be an incredibly effective way of gleaning tons of new insight from old data.
posted by killdevil at 2:12 PM on June 11, 2009

So I have several friends with LBP. They visit chiropractors occasionally (paid for by health care) and always feel better afterward, admittedly it does not last for more than a couple of weeks. What other low-cost low-barrier-to-entry options would be better for them?*

* fortunately I have no LBP, and if you mention energies or alignments to me, I will probably slap you. That being said, they seem to feel better after.
posted by blue_beetle at 2:12 PM on June 11, 2009

That isn't the only meta-analysis that's ever been done, This paper which I also linked too, is a meta analysis, spanning 887 different studies.

Delmoi, the meta-analysis which you have posted does not perform the same comparisons as that sourced from the Cochrane database; instead of comparing chiropractic to other forms of treatment, it compares differing forms of chiropractic treatments to each other. Review the conclusions in the abstract.

Again, this was published a peer reviewed journal and published on Pubmed, which is run by the U.S. National Library of Medicine and the National Institutes of Health.

Peer review is a quality filter, but depending on the journal environment it is not necessarily a strong one. Pubmed listing should never be used as an indicator of quality; it is an indexing service and provides almost no comment on content or validity, besides a general 'scienciness' of the publication.

The Cochrane review that has been presented actually supports your assertion that chiropractic SMT is an efficacious treatment for lower back pain; however this effect, like all other interventions considered, is quite modest, and in the context of the meta-analysis cannot be distinguished efficacy-wise from most other helpful interventions. This is faint praise, but not damning, for this best supported aspect of chiropractic practice.

One area where chiropractic medicine is particularly strong, an aspect which it shares with many other areas of complementary or alternative medicine, is in overall patient satisfaction, which is often found to be considerably higher, despite equivalent or inferior efficacy of the treatments that they provide. While explanations for this effect can be made that are positive (better addressing of patient emotional needs) or negative (overpromising), allopathic physicians need to think hard about why this differential is so apparent.

I do think that several critiques of chiropractic are very reasonable. First, chiropractors often branch out of their core demonstrated competencies, making claims of efficacy for SMT in a range of diseases that borders on the farcical, such as asthma, celiac disease, and so on. While these woo types are mixed in with practitioners who claim a far more limited purview, even the 'traditional' chiropractic domain is relatively poorly supported, often with poor methodological techniques as has been previously pointed out. Furthermore, the 'reasonable' core of chiropractors has been poor at condemning their peers who make outlandish claims about the applicable scope and efficacy of their treatments. The poor quality of the literature available brings to light a frequent dilemma in biomedicine: the current studies show no difference between techniques, but it is not clear if this is indication of a real equivalence or simply of a lack of power in the available evidence.

The second critique would involve poor scientific support for the core practice of SMT. While the intervention may in fact be helpful, the underlying mechanism proposed may not be correct; SMT may simply be replicating the mechanism of other techniques under another auspice. The pretty low quality of the science in the chiropractic literature does not help here in determining whether this is the case.

If at some point I were to be in the legal and practical position to recommend back pain treatment to a patient, I would not recommend a chiropractor, instead selecting one of the other care methodologies considered in the Cochrane review which is better . That said, for this limited domain I wouldn't object if a patient selected that option, unless there was some large shift in the available evidence.
posted by monocyte at 2:16 PM on June 11, 2009 [5 favorites]

killdevil: I think you missed the point about the meta-analysis. It was a pun, not a commentary on the validity of meta-analysis as a research tool.
posted by jedicus at 2:25 PM on June 11, 2009

The Cochrane review that has been presented actually supports your assertion that chiropractic SMT is an efficacious treatment for lower back pain; however this effect, like all other interventions considered, is quite modest, and in the context of the meta-analysis cannot be distinguished efficacy-wise from most other helpful interventions. This is faint praise, but not damning, for this best supported aspect of chiropractic practice.

Given that "lower back pain" is a pretty wide net that can be caused by a variety of underlying problems, it may be that some of these causes are helped by chiropractic treatment while others are not. My personal experience is that neither regular doctors nor chiropractors really do particularly extensive diagnosis beyond an x-ray to ensure that you haven't got a ruptured disc or something equally grossly wrong. So there's the possibility that the studies don't adequately segment the patients to see which ones benefit versus which ones aren't improved by chiroprody.

And while I think chiropractic treatment has its place, let me issue the I-have-a-brain disclaimer which is that beyond back and some other types of joint pain, obviously chiropractors can't cure diabetes or anything like that. I too wish that reputable chiropractors would spend more time rebuking the quacks and that the quacks would go away. This lawsuit is definitely nonsense.
posted by GuyZero at 3:05 PM on June 11, 2009

Chiropractors, they really get my back up!
posted by Abiezer at 3:34 PM on June 11, 2009

So I have several friends with LBP. They visit chiropractors occasionally (paid for by health care) and always feel better afterward, admittedly it does not last for more than a couple of weeks. What other low-cost low-barrier-to-entry options would be better for them?*

Yoga. But that would require...effort.
posted by docpops at 5:11 PM on June 11, 2009 [1 favorite]

Fourcheesemac, you say:

There is no legitimate body of science for "chiropractice." What there is is, like all alt med bullshit, alt med bullshit.

I am under the impression that you are a social scientist. How are you qualified to assess the scientific foundations of chiropractic science?

(I have no position with regard to the merits of chiropractic science, have never been to a chiropractor, and my closest encounter with "chiropractic" was a very brief acquaintance with someone who practiced "Nucca" chiropractic, and he seemed like a world-class bullshitter. However, I have heard enough good things from people who have been treated by chiropractors to wonder what kind of expertise you have to dismiss it out of hand.)
posted by jayder at 7:47 PM on June 11, 2009 [1 favorite]

There are many, many thousands of studies available via PubMed whose content is scientifically suspect. Getting an article published, even in a reputable journal, is no guarantee as to the quality of the research it reports on. I mean, this guy got 28 totally fraudulent papers published in Nature, Science and Physical Review. If your research is sexy, and particularly if it purports to upend traditional thinking in its topic area, it's not terribly hard to get your articles into prestigious pubs.

You realize you're making the same arguments as anti-vaccination people and global warming denialist, right? I mean that the science is all cooked and corrupted and so on. And I'm sure there are all kinds of biases and whatnot. But keep in mind these are meta-studies. One of the ones I linked too was an analysis of 887 other studies. The other one that TedW linked too also didn't say chiropractic care didn't work, just that it didn't work better then other medical care.

Once you start saying "the science is all bogus" you're really down the rabbit and argument becomes impossible unless you're really an expert. Simply making ad-hominem attacks against the authors of the studies, claiming that NIH and peer-reviewed science journals don't have high enough standards, etc, that's just not a real argument. It certainly isn't a scientific argument at all. In fact, that's exactly the techniques used by anti-science types all the time.

I do think that several critiques of chiropractic are very reasonable. First, chiropractors often branch out of their core demonstrated competencies, making claims of efficacy for SMT in a range of diseases that borders on the farcical, such as asthma, celiac disease, and so on.

I agree, and it would be nice if they policed themselves better.

If people don't think being published on pubmed is good enough, what do you think is a good metric to use to the judge the quality of "the science" without being an expert in the field?
posted by delmoi at 8:52 PM on June 11, 2009

My bullshit test is pretty simple. Does your health care provider require you to sign a waiver before they will treat you?

Chiro - yes

Medical doctor - No
posted by unSane at 9:59 PM on June 11, 2009 [1 favorite]

delmoi is a chiro-nut huh? You know, that's really funny. You see all these people here who seem pretty even-headed and you read all their comments and you see they have some really informative things to say and you kinda get to know them in an internet kinda way. Then eventually some topic comes up and you find out that wait, they have some psycho-babble proclivity that kinda negates what you thought of them. And you remember that and probably bring it up at a later time. Funny how that works.
posted by dead cousin ted at 10:52 PM on June 11, 2009

You see all these people here who seem pretty even-headed and you read all their comments and you see they have some really informative things to say and you kinda get to know them in an internet kinda way.

And who the fuck are you?
posted by delmoi at 11:58 PM on June 11, 2009

Also:

My bullshit test is pretty simple. Does your health care provider require you to sign a waiver before they will treat you?

Chiro - yes

Medical doctor - No

Other then a privacy waver for billing, I've never had to sign a waver.
posted by delmoi at 12:03 AM on June 12, 2009

I too have never signed any waiver. FWIW, Ontario (OHIP) used to pay for chiropractic treatment until 2004 when they cut it along with physiotherapy and eye exams for adults. Not that that proves anything.
posted by GuyZero at 12:33 AM on June 12, 2009

"My bullshit test is pretty simple. Does your health care provider require you to sign a waiver before they will treat you?

It's kinda funny to me that while the previous two folks say they've never waived anything, I had to sign an elaborate waiver/arbitration agreement with my PCP (the acronym cracks me up) before I could get a physical.
posted by klangklangston at 2:29 AM on June 12, 2009

delmoi: You don't have to be an expert but in many cases it is pretty simple to read and article and discover whether or not the science is quality as long as you have an understanding of the scientific method and experiment design.

This, of course, is done with an understanding that you probably wouldn't understand if the basic science is wrong. The problem here is that you have to trust the review committee not to give a pass to something that is wrong on a fundamental level rather than an experimental level.
posted by Loto at 6:08 AM on June 12, 2009

had to sign a couple waivers for my PCP - never for my chiropractor

and, just to throw my anecdote into the ring: i have been to general practitioners, sports therapists, physical therapists, x-rays and all - not one of these options resulted in any relief for my back pain

first time i went to my chiropractor i entered her office barely able to walk upright - one hour later i left feeling like i was walking on air - yes i know that sounds like an exaggeration, but it was how i felt

what's more: over time my chiropractor has taught me a variety of stretches and exercises that has led to me being able to manage my back problems myself - this has also resulted in my seeing her less, which she seems quite happy about - it has also led me to be fitter overall - it is the only time i can remember a medical practitioner teaching me how to heal myself

here's a question: if science has shown that chiropracty produces no real medical benefits or results, how should i interpret my experience?
posted by jammy at 6:31 AM on June 12, 2009

if science has shown that chiropracty produces no real medical benefits or results, how should i interpret my experience?

It hasn't quite shown that. For example, as discussed above, it's as effective as medical treatment for chronic lower back pain but more expensive. You seem to be describing chronic back pain, given the number of treatments you tried before seeing a chiropractor. Medical treatment is not 100% effective, and clearly you fell into the group for whom it does not work. Given the difference in treatment modality, it's not surprising that chiropractic therapy might succeed where medical therapy failed for you.

But we can't extrapolate from that one case to say that anyone who can't get adequate relief from medical treatment should see a chiropractor. It would be interesting to see a study that examined the success rate of chiropractic therapy given to people whose back pain could not be controlled or treated with medical therapy. It could be that although chiropractic and medical therapy are equally effective for long term back pain that they are effective on two mostly disjoint groups. Or it could be that your case is unusual.
posted by jedicus at 7:39 AM on June 12, 2009

Osteopathy vs Chiropractic. The former engages with the scientific method, the latter does not.
posted by meehawl at 8:26 AM on June 12, 2009 [4 favorites]

Medical treatment is not 100% effective, and clearly you fell into the group for whom it does not work. Given the difference in treatment modality, it's not surprising that chiropractic therapy might succeed where medical therapy failed for you. ... Or it could be that your case is unusual.

jedicus - i realize that science is in part based upon a contempt for the particular case but i've never thought of myself as that special or unusual - you make me sound like a mutant :)

could you extrapolate on what you mean by "the difference in treatment modality" and why this would account for science-based medical procedures failing me while apparent quackery got the job done?
posted by jammy at 11:18 AM on June 12, 2009

the difference in treatment modality

Medical therapy for back pain is based mostly on analgesics, lifestyle changes, and (more drastically and less commonly) surgery. Those are very different than chiropractic therapy, which does not use drugs, is a treatment rather than lifestyle change, and is nonsurgical. Because chiropractic therapy works or purports to work in a different way, one can imagine that some back pain might be treatable by one but not the other.

For example: analgesic therapy blocks the pain in the hope that restoration of regular posture and movement will lead to self-correction of the problem. But what if regular posture and movement cannot be restored because of a mechanical issue with the spine or that the problem is not susceptible to self-correction?

Lifestyle changes focus on exercise, posture, and weight loss, but what if the problem does not derive from any of those? Surgery is a direct physical intervention like chiropractic therapy, but what if unavoidable trauma associated with surgery only makes the problem worse?

So you can imagine a problem that the usual medical treatments don't help with and that chiropractic therapy might work for. The question I raised was whether that kind of case is common (i.e., the medical-therapy-beneficial and chiropractic-therapy-beneficial groups are largely disjoint) or whether it's comparatively rare, which would make your case unusual.

If the groups are disjoint, then a method for figuring out which group a patient falls in ought to be devised. But if chiropractic care is only rarely useful when medicine fails, then that further reduces its already small value. In fact, I would say that if the latter case is true, then worthwhile chiropractic techniques ought to be subsumed under physical therapy or standard medical therapy and the whole notion of chiropractic as a separate discipline done away with along with its pseudoscientific trappings.
posted by jedicus at 11:35 AM on June 12, 2009

It hasn't quite shown that. For example, as discussed above, it's as effective as medical treatment for chronic lower back pain but more expensive. You seem to be describing chronic back pain, given the number of treatments you tried before seeing a chiropractor. Medical treatment is not 100% effective, and clearly you fell into the group for whom it does not work. Given the difference in treatment modality, it's not surprising that chiropractic therapy might succeed where medical therapy failed for you.

Which is another important point. Even if chiropractic care and 'standard' medical treatment work was well as eachother on average, there are probably going to be cases where Spinal Manipulation Therapy works (whether done by a chiropractor or not) better then regular medical care and other cases where it doesn't work as well. But writing off all chiropractors would mean excluding that group of people from relief. I also think the cost argument varies a lot as well.
posted by delmoi at 2:29 PM on June 12, 2009

Delmoi

The dismissal of your meta analysis isnt because of a distrust of science a la anti-vax or gw deniers, it's becuase

meta-analysis which you have posted does not perform the same comparisons as that sourced from the Cochrane database; instead of comparing chiropractic to other forms of treatment, it compares differing forms of chiropractic treatments to each other. Review the conclusions in the abstract.

Your meta analysis is innapropriate and irrelevant to the discussion at hand. You have not cited a serious meta analysis supporting your position.
posted by lalochezia at 4:59 PM on June 12, 2009 [1 favorite]

So I have several friends with LBP. They visit chiropractors occasionally (paid for by health care) and always feel better afterward, admittedly it does not last for more than a couple of weeks. What other low-cost low-barrier-to-entry options would be better for them?

A physiotherapist and an occupational therapist? The former will work with the tissue injuries; the latter will help them figure out what they are doing that's causing them back pain — poor seating, wrong desk height, lifting improperly, etceteras.
posted by five fresh fish at 5:24 PM on June 12, 2009

Your meta analysis is innapropriate and irrelevant to the discussion at hand. You have not cited a serious meta analysis supporting your position.

lalochezia: none of the other studies posted have said that Spinal Manipulation Therapy didn't work, they have all said that they work as well for chronic lower back pain. Even the links jeducius posted in the beginning of the thread.

Even the Cochrane review linked by TedW simply said that chiropractic care wasn't superior to other treatments, not that it didn't work or that it was less effective.

I actually do have other things to do besides reading medical papers all day (and most of these are behind pay walls anyway) The point is, there are many studies and meta studies that show that Chiropractic care works.

The problem is with any kind of specific scientific document, anyone can come up with specific criticisms and complaints, and try to use that to those specific complaints to argue against the conclusions. That's exactly the technique used by antivaxers, by creationists, etc. Rather then bringing up real research that backs their conclusions, they simply snipe at what's out there.

If you don't think Spinal Manipulation Therapy works for lower back pain, then go find some studies that say that. Until then, simply criticizing existing studies and dismissing them is pretty meaningless.
posted by delmoi at 8:51 PM on June 12, 2009

Until then, simply criticizing existing studies and dismissing them is pretty meaningless.

By this logic, we should all believe in psychic powers, since showing that the studies which "prove" psychic powers are real are all horribly flawed is meaningless.
posted by Pope Guilty at 9:47 PM on June 12, 2009

I'm looking into your mind, Pope Guilty, and I can tell that you don't really mean that.
posted by five fresh fish at 10:43 PM on June 12, 2009

By this logic, we should all believe in psychic powers, since showing that the studies which "prove" psychic powers are real are all horribly flawed is meaningless.

I'm talking about papers and studies published in legitimate journals and posted on sites like pubmed. Obviously there are some sources which are not legitimate. But for a layperson to review the scientific validity, the best way to do it is by looking at the legitimacy of the source.

I think once a paper has been accepted by a legitimate source you really have to come up with other studies or research (which are also "legitimate") that disproves it. You can't just nitpick the methodology. You see those arguments all the time from people who disagree with mainstream science: from Michael Crichton arguing against global warming to rightwingers who disagreed with the Lancet study on Iraqi deaths, to creationists, and on and on.

Of course sometimes scientific studies are overturned, the physics fraud mentioned above is one example, another would be this study on the effects of Ecstasy which was withdrawn when it turns out they were giving rats the the entirely wrong drug.

The irony is that people here are arguing that they are the "defenders of science" are actually ignoring actual scientific results and arguing using the same methods as all the anti-science people out there. (not that lots of chiropractors don't believe lots of crazy stuff, they do. But Spinal manipulation for lower back pain is well proven. It doesn't need to be done by people who believe all the psudoscience, though).

The fact is, the people who think that spinal manipulation therapy (done by a chiropractor or not) doesn't do anything are the actual cranks. They're the ones who are wrong about what mainstream science actually says.
posted by delmoi at 12:48 AM on June 13, 2009 [1 favorite]

They're the ones who are wrong about what mainstream science actually says.

It's interesting that you now see yourself the arbiter of "what mainstream science actually says" to the point that you can call scientists cranks. It's a bit amusing given your poor understanding of how science actually works. (Inclusion in PubMed is now the gold standard? Really? More like the bare minimum. And we can't critique other scientists' conclusions anymore? Really?)

Mainstream science often does not deal with certainties. Some hypotheses are considered sufficiently probable that they are treated as certainties. The hypothesis that spinal manipulation helps chronic lower back pain is not one of these. A BMJ Clinical Evidence review of 11 different modalities for treating chronic lower back pain considered the evidence of symptom or functional improvement from spinal manipulative therapy "very low-quality evidence" when assessed in the GRADE framework, after considering the results of the Cochrane review and others.

An accurate statement of "mainstream science" on spinal manipulative therapy cannot be reduced to a sound bite such as "chiropractic care works." Instead it would be more like this:

There is "very low-quality evidence"¹ that spinal manipulative therapy provides a treatment of "modest effectiveness"² for chronic low back pain, when compared to placebo. There is no evidence² that spinal manipulative therapy provides superior treatment to other advocated treatment methods.

A bit less snappy than "it works" but much more accurate. There's still the problem, however, that there is really no "truly effective therapy"² for lower back pain. Back exercises might have "low-quality" instead of "very low-quality" evidence for moderate effectiveness but that's not really that compelling. So in this case vociferously arguing for any particular kind of therapy is quite incorrect and unscientific.

Why, then, the opposition to patients visiting chiropractors? As has been noted many times, many chiropractors will advocate spinal manipulation as a treatment for non-musculoskeletal conditions such as asthma or ear infections for which there is not only zero evidence of effectiveness, but also almost no conceivable way they could be effective given our understanding of medical science. While a few chiropractors decry this highly unethical practice, the chiropractic establishment (in the form of the British Chiropractic Association and others) defends it, advertises it, and even attacks those who point out the lack of evidence (hence the BCA's lawsuit against Simon Singh, the ultimate cause for this post). The chiropractic establishment in Britain and the U.S. have utterly failed to keep their own houses in order and that's why there is a great deal of mistrust for chiropractors. So you will forgive me, I hope, for having a little less regard for The Journal of Manipulative and Physiological Therapeutics, the house journal of the American Chiropractic Association, and the several papers which appeared in it cited above.

Even if one accepted that spinal manipulation were a good idea, given the failure of chiropractic regulation, how could one have any hope of believing that the chiropractor one visited for this service would apply it in an effective way, or even a way that was not harmful (consider the evidence for increased risk of stroke after spinal manipulation)? Getting beyond that, even if one thought that a chiropractor would safely and effectively apply spinal manipulation, how could one possibly advocate that other patients, who are perhaps a little less well-informed than those here, and may even be in a vulnerable state, place their medical care in the hands of a chiropractic who might then abuse the established doctor-patient relationship to sell them unproven (and sometimes preposterous) chiropractic therapies for conditions for which good medical treatments are available?

In summary, there aren't great reasons to believe in the efficacy of spinal manipulation, but if you want it nonetheless, get it from an osteopath.

¹ BMJ Clinical Evidence review.
² Cochrane review.
posted by grouse at 10:41 AM on June 13, 2009 [6 favorites]

Obviously I don't think that people should be sold on bogus treatments for other conditions by charlatan chiropractors. But the argument that SMT does nothing whatsoever is not correct, and that's what I was disputing.

It would be a more compelling argument if we knew exactly how many chiropractors are charlatans and how many stick with lower back pain. There are plenty of MDs who are quacks as well (Dr. Akins of the Atkins diet comes to mind) Plenty of MDs get involved in alternative medicine and quackery as well.

Just googling around brings this guy

Functional Medicine evaluates how well specific healing systems perform and identifies those that are weak.

Natural therapies can support these crucial functions and remove crucial obstacles to healing. Our natural healing systems integrate their function through a tight web of communication. Therefore, strengthening any one system should have the effect of helping healing overall.

Which sounds pretty Quacky to me, but that guy is (or claims to be) an MD. I'm certainly not saying that MDs are just as likely to be quacks as chiropractors, but they are certainly out there.
posted by delmoi at 8:39 PM on June 13, 2009

Geeks are having fun scraping websites and automailing complaints about unsupported claims. Heh.
posted by five fresh fish at 8:22 PM on June 15, 2009 [2 favorites]

Oh, and even better, geek are organizing to deal with homeopathy awareness week. Awesome.
posted by five fresh fish at 8:25 PM on June 15, 2009 [1 favorite]

jayder, to follow up, my evaluation of chiropractic quackery stems from a broader social scientific interest in quackery (and risk/benefit perception) in general, as a cultural phenomenon. But my identity as a social scientist is irrelevant to my judgment of chiropractic "science." The critique I represented above is one that, it seems to me, any rational person would agree with.

The strange split-the-difference defense -- well, some chiropracters are quacks and the underlying theory upon which the "discipline" was built is bullshit, but they don't all believe it any more -- baffles me. It's like saying some 3-card monte dealers really will let you win sometimes to keep the con going.
posted by fourcheesemac at 1:10 PM on June 17, 2009