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The accumulated data of higher-quality studies that been performed on spinal manipulation.

I meant this to be a relaxing week. I am meeting my wife in Vegas for a long weekend of desert hikes, food, drink and shows. I was not going to write any blog posts, record podcasts or in any manner work on my multi-media empire. I was actually planning on reading Thunderbird on the flight, which I have been saving like a fine whiskey for an extended quiet time.

Nope. The New York Times had to go an publish “For Bad Backs, It May Be Time to Rethink Biases About Chiropractors” right after my Friday extravaganza, “Spinal Manipulation and the JAMA Meta-Analysis: An Analysis of Fuel.” Sigh. Doody [sic] Calls.

I will be brief. And a warning: I am smug skeptic, and as such I am armed with “copious amounts of mockery.”

As an ID consultant I am used to seeing people screw up ID cases. ID is more than picking an antibiotic off the culture and sensitivity report. Others often do not understand the significance of the S. aureus in the blood, or why ciprofloxacillin [sic] is a poor choice to treat the infection. No one would treat cancer without an oncologist or MS without a neurologist, but some will flail about treating infections as if they know what they are doing. They don’t.

It is often because the physicians have not taken the time and effort, or do not have the time, to look it up, because in the era of Google, Pubmed, and UpToDate looking something up is just so hard. They assume a superficial knowledge gleaned from an electronic guide is a substitute for knowledge and real expertise. There is a lot background to ID, or any other medical field, that needs to be known to really understand disease. It is no surprise ID consultation leads to decreases in mortality and morbidity for a variety of infections. Gee, having someone who actually knows what they are doing makes a difference in patient outcome. Who da thunk it?

It is ‘nice’ to see a similar approach applied to the pseudo-medicine in The New York Times, sort of a metaphorical project Alpha researchers approach to spinal manipulation.

Let’s see what the author, a pediatrician and professor, has to say:

Spinal manipulation — along with other less traditional therapies like heat, meditation and acupuncture — seems to be as effective as many other more medical therapies we prescribe, and as safe, if not safer.

I will focus on spinal manipulation component. As I noted on Friday, efficacy is more than suspect. It is risible.

But safe? Reviews of spinal manipulation from:

two prospective reports suggested that relatively mild adverse effects occur in 30% to 61% of all patients.

How about stroke? As if chiropractors are going to limit their pseudo-science to the low back? The entire spine is their alleged purview and it must be aligned from top to bottom and from birth to death. Tell Nicole Rhodes, the most recent victim of chiropractic pseudo-science, that chiropractic is safe:

it was neck manipulation by chiropractor that triggered her stroke.

No treatment of a self-limited illness should have as its potential complication a stroke, no matter how rare the complication.

Most back pain resolves over time, so interventions that focus on relief of symptoms and allow the body to heal are ideal.

One of the classic pseudo-medical concepts with no real content. Back pain gets better. So how do you know these interventions are the reason the symptoms improve?

And I thought that chiropractors were getting at the root cause of the problem, a subluxed spine blocking innate intelligence, and not treating just symptoms.

So just how does spinal manipulation “allow the body to heal”? The body is healing anyway, with or without the spinal manipulation. And I would point out that pain is the body’s way to say “stop it’ and not adding to the trauma. If you block symptoms you stop protecting the damaged area and probably delay healing. Tell Bill Walton relieving the symptoms of foot pain was helpful.

Physicians are traditionally wary of spinal manipulation (applying pressure on bones and joints), in part because the practitioners are often not doctors and also because a few chiropractors have claimed they can address conditions that have little to do with the spine.

Well, I would argue with a fictional understanding of the spine, chiropractors cannot really address conditions of the spine either.

And few? Been to Mantioba recently?

Based on the Manitoba Chiropractors Association membership listing, there are approximately 275 licensed practitioners working out of 215 offices. CBC News found questionable online content linked to more than 30 chiropractic offices.

Pseudo-science is intrinsic to chiropractic.

He continues:

Almost a decade later, a Cochrane review assessed the literature once more, and found 12 new trials had been conducted. This review was more damning. It found that spinal manipulation was no better than sham interventions.

When a procedure is no better than sham, it means no efficacy. But then…

But since then, data have accumulated, as more higher-quality studies have been performed.

Ohhhhh. Higher quality studies. These I have to see. And just where were those higher quality studies to be found?

Recently, in The Journal of the American Medical Association, researchers looked for new studies since 2011, as well as those that had been performed before.

Yes, the same heap of cow pies I reviewed last week. I suspect, like I so often see in how others practice ID, the author did not do the due diligence of actually looking at the primary literature contained in the meta. Because there are no high quality studies in that article. Anyone who reads more than the Cliff Notes version of the meta and actually dug into the literature would never conclude:

The evidence from 12 randomized controlled trials — which overlapped, but not completely with the other trials — of almost 1,400 patients showed that spinal manipulation also resulted in improvements in function.

The author then points to “Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians” as supportive of spinal manipulation.

That guideline contains that great mystery of all the guidelines: how they can make strong recommendations based on low-quality evidence? Got me. It is the alchemy of guidelines, turning digested straw into spun gold.

Here is the text. The effect of spinal manipulation is unimpressive:

Low-quality evidence showed that spinal manipulation was associated with a small effect on function compared with sham manipulation; evidence was insufficient to determine the effect on pain. Low-quality evidence showed no difference in pain relief at 1 week between spinal manipulation and inert treatment (educational booklet, detuned ultrasound, detuned or actual short-wave diathermy, antiedema gel, or bed rest), although 1 trial showed better longer-term pain relief (3 months) with spinal manipulation. Function did not differ between spinal manipulation and inert treatment at 1 week or 3 months. Moderate-quality evidence showed no difference between spinal manipulation and other active interventions for pain relief at 1 week through 1 year or function (analyses included exercise, physical therapy, or back school as the comparator). Low-quality evidence showed that a combination of spinal manipulation plus exercise or advice slightly improved function at 1 week compared with exercise or advice alone, but these differences were not present at 1 or 3 months

Anyone impressed? Not me. It is the usual pseudo-medical analysis, a hodgepodge of weak studies show marginal aka placebo effect.

The only things that might detract from the use of spinal manipulation in this situation would be its cost and potential harms.

Medicine is about cost and benefit. With no good benefit, it should have no cost and no harm. But chiropractic offers only harm and cost. And suggesting a patient waste time and money based on this kind of data is not my idea of good medical advice.

Medication and surgery can also lead to harms. We shouldn’t forget that prescription pain medications, like opioids, can lead to huge costs, especially when they’re misused.

Medicine can be dangerous, but medicine and surgery actually have real effects. The argument is because medicine has issues we should instead use pseudo-medicine? Great idea. Where would we be without the old, “There are problems with airplanes, so let’s rely on magic carpets” argument.

And:

Some physicians are uncomfortable that we don’t have a clear picture of how spinal manipulation actually works to reduce pain. It’s also possible that some chiropractors do it “better” than others, and we can’t tell. This concern should be tempered by the fact that we don’t have a great understanding of why many other therapies work either. Some of the more traditional things we recommend don’t even work consistently.

A careful reading of the spinal manipulation literature and an understanding of the pitfalls of research in pseudo-science like chiropractic gives a clear picture of how chiropractic works. It doesn’t. It is placebo and it is considered unethical to offer placebo.

This is what comes from applying the standards of science to pseudo-science. His idea that treating:

infantile colic, painful periods, asthma, gastrointestinal problems, and more.

With chiropractic is not a good idea is not that chiropractic is pseudo-science not grounded in reality. Nope. It is because:

the therapy lacks a good evidence base.

Give up a ‘bias’ against a medical fiction? Might as well say we should give up our bias against Ai Sedai healing. And while we are at it, abandon bias and add astrologers to NASA. We don’t have a clear understanding how astrology works, but a large and growing number of Americans think it is valid and its proponents and adherents say it works.

That is modern medicine: promoting all the variations of the curse removal scam disguised as science. The researcher wears no lab coat.

And he finishes with the same empty pseudo-science mantra:

But given the natural course of back pain — that most of it goes away no matter what you do — the ideal approach is to treat the symptoms and let the body heal. Noninvasive therapies seem to do that well enough.

For spinal manipulation there is no compelling symptom relief and it does nothing to let the body heal. Healing happens on its own, with the exception that a wallet relieved of its cash has less pull on the lower back.

So when I see a headline like “Feds reach $1 million settlement with Kansas City area chiropractor” because:

procedures that the government contended were not medically necessary.

I suggest that ‘not medically necessary’ defines chiropractic.

While searching the web looking for the author’s other writhttp://www.404errorpages.com/ings on chiropractic and spinal manipulation I did find that he is also the author of “Labels Like ‘Alternative Medicine’ Don’t Matter. The Science Does“, which is true, but…

No irony there. No siree Bob

Time to put my seat back in the locked and upright position. I hope to be gone until Monday.

Later.

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at edgydoc.com.