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Re: Chiropractic madness!!!!!!!!!!!!
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Re: Chiropractic madness!!!!!!!!!!!! - April 7, 2002 5:45:00 PM
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Sebastian Asselbergs
Posts: 1089
Joined: September 29, 1999
From: Barrie, Canada
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With the proper training (from an accredited institute), physios in Canada can become acupuncturists (some variety accross the provinces). Their acupuncture is under the standards of practice of the professional physio bodies and their professional colleges.
There is quite a bit of elegant research on the effects of acupuncture - some in support some inconclusive, some no better than placebo. Do extensive medline searches (make sure you use fMRI in one of them - neat results). But at least there is a lot of research!
Chiroguy, I wish you well in this discussion, but I feel your profession has a lot of very poor practice to overcome.
If you want to start a new thread with regards to some of the crap some physios use as practical techniques, feel free. (I'll probably then agree with a lot you'll have to say0. BUT, it should be a different thread.....
Sebastian
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Re: Chiropractic madness!!!!!!!!!!!! - April 7, 2002 8:56:00 PM
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ChiroGuy
Posts: 63
Joined: January 24, 2002
From: Toronto, Ontario, Canada
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Bobcat,
I prefer playing "Stairway to Heaven" on my air guitar in my spare time. How 'bout you?
ChiroGuy
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Re: Chiropractic madness!!!!!!!!!!!! - April 11, 2002 8:38:00 PM
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ChiroGuy
Posts: 63
Joined: January 24, 2002
From: Toronto, Ontario, Canada
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I found this information and thought that in light of all the hoopla that is being (or about to be) made about chiropractic manipulation causing stroke it might be of interest and put things into perspective. As some of you may know, a Coroner's Inquest will be commencing in about a week in Toronto to look into whether chiropractic played a role in the death of a local woman. The case is unbelievably tainted with scandals (the woman's heart was lost from the coroner's office, a lead medical "witness" was banned from the proceedings because he threatened the Chief Coroner, etc), lack of good evidence, abundance of faulty evidence, and extreme media bias. In a recent study performed by an independent research team, it was found that over the past 6 years in Ontario, a grand total of 6 strokes were ASSOCIATED with chiropractic treatment (keep in mind this says nothing of causation). This was to date the largest chiropractic stroke study ever undertaken in Canada, and looked at all stroke admissions to Ontario hospitals. I don't have the reference handy, but can find it if anyone wants it. We've been informing people for years that many activities of daily living can cause VBI, but no one seems to listen other than when chiropractors are involved ....
Cervical Vertigo After Hair Shampoo Treatment at a Hairdressing Salon: A Case Report
Spine 2000; 25 (5) Mar 1: 632–634
The authors suggest that the hyperextended neck position during hair shampoo treatment in a beauty parlor may be a risk factor for back lifting or cerebellum vascular insufficiency. Public education should lead to avoidance of this position during hair shampoo treatment at hair dressing salon.
Salon Sink Radiculopathy: A Case Series
Am J Phys Med Rehabil 1999; 78 (4) Jul–Aug: 381–383
We present two patients with cervical radiculopathy that was significantly exacerbated after the patient's hair had been shampooed in a salon sink; subsequently, these patients required oral administration of steroids. These cases illustrate that patients with suspected or known cervical radiculopathy should be forewarned to avoid this otherwise seemingly innocuous activity.
Vertebrobasilar Disease Beauty and Beauty Parlor Stroke Syndrome
Am Fam Physician 1995; 52 (5) Oct: 1287–1290
Beauty Parlor Stroke: When a Beautician Becomes a Physician
JAMA 1993; 270 (10) Sep 8: 1198; Discussion 1198–9
Beauty Parlor Stroke Syndrome: Report of Five Cases
JAMA 1993; 269 (16) Apr 28: 2085–2086
Beauty Parlor Stroke: The Injuries Continue
Geriatrics 1995; 50 (10) Oct: 14
I thought this was quite interesting, especially considering that local hair dressers have not been barraged with demands to stop washing hair and claims that one should never have their hair washed again to prevent stroke. I think I'll have to recommend that patients start taking prescription drugs to prevent the release of oils from sebacious glands in the scalp rather than risk their lives by washing [IMG]http://www.rehabedge.com/forums/wink.gif[/IMG]
Chiroguy
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Re: Chiropractic madness!!!!!!!!!!!! - April 12, 2002 4:46:00 AM
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Andrew M. Ball MS MBA PT
Posts: 271
Joined: September 30, 2001
From: Chapel Hill
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Chrioguy,
I think that SJ is missing the point. Nothing that I read in your post suggested that hairdressers "rack-em-up" and chiropractors "knock-em-in" when it comes to brainstem strokes. SJ, I think, is assuming that you're saying that chiropractic induced strokes are actually caused by years of hairdressing. I didn't get that you were trying to show a cause and effect relationship between the two.
What I am hearing, however, is that in your opinion, because hairdressers place clients in a position of vertebral insufficiency, that the experts of NeuroMusSkel function (the DPT's, DScPT's and DC's alike), should stand up and try to educate the public. I agree.
To say that this problem should be of equivocal concern to the lay pubic as chiropractic-induced brainstem strokes, however, is irresponsible. Unless the patient has A-A instability, hyperextension of the neck causes only temporary restricted blood flow to the brain --- a headrush follows. Usually, however, if the customer beings to pass out, they are returned to sitting, and all is well. There are, of course, a small %age of people who are going to stoke out for reasons poorly understood by the hairdresser.
With grade v mobilization, chiropractic manipulation, or adjustment, a false move can lead to immediate, permanent, and irreversible brain damage at the brainstem. The difference, therefore, is in scope and severity of injury. When chiropractic therapists/practitioners scream that as a profession, they are overscrutinized --- they may have a point. BUT, that doesn't mean that they should be free from scrutiny altogether. The latter, and in my opinion, more pervasive position among chiropractic therapists/practitioners, is what scares the healthcare community --- and rightly so. It demonstrates a paucity of logic, and a willingness to place professional ego over the safety of the patient.
The pervasive chripractic preventative medicine approach, combined with the risks (however miniscule) of brainstem stroke seems to me to be unacceptable, especially in assymptomatic patients. I can understand hairdressers not having the education or skill to develop better and better clinical tests so as to ADMIT, RECOGNIZE, and MINIMIZE the problem --- but chiropratic therapists have no excuse. As a group, in my experience, they tend to choose a pre-defensive posture over the ethical and professional practice of admitting the shortcomings of their treatments, and working to enhance effectiveness and reduce risks.
A profession that tries so despirately to hold itself up and out as a "doctoring profession," self-proclaiming themselves to be "chiropractic physicians" will never evolve from, the current status of highly skilled chiropractic technician/therapist/practitioner if it continues to respond to critique in such a non-physician, non-professional, technician-oriented manner.
Drew
[This message has been edited by Andrew M. Ball MS MBA PT (edited April 12, 2002).]
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Re: Chiropractic madness!!!!!!!!!!!! - April 12, 2002 5:00:00 AM
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researchdoc
Posts: 34
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Chiroguy-
I'm not really sure what it is with chiropractors, but they seem, as do you, to be a little trigger happy with this whole "stroke" thing. Regarding the "hoopla" you speak of- on this particular thread, the subject of strokes with manipulation was first raised by a chiropractor with the moniker "doc4bax", who stated "Also if you really dig for the information concerning stroke and cervical manipulation (because I’m sure you’d bring this up) you will find that ..."
So, here was a chiropractor who brought the subject up, because, well, he was "sure" that others would.
And now you- the only other discussion of this stroke/manipulation link was when you tried to denigrate the medical profession by claiming that NSAIDs were more dangerous than manipulation. And in this context, "strokes" were not really discussed at any length, except as they relate to the risk/benefit of SMT for cervical pain.
Now you are discussing the "hoopla" surrounding strokes and manipulation...I just don't get it. What is with chiropractors that they are so defensive? OK, fine. You want to talk strokes, then we can talk strokes.
#1- Comparing stroke from manipulation to "beauty parlor strokes" is a red herring- many many everyday activities can cause strokes- but to attempt to use this fact as a shield against criticism of your chosen method of therapeutic intervention is just plain wrong.
As a health care provider, you have a certain responsibility to the public- that is to accurately and determinedly define the risks and benefits of what it is that you do. Rather than resort to logical fallacies to try to deflect criticism and inquiry into your profession, it would be better to simply acknowledge the risks, develop some kind of reporting and assessment system, and work on reducing the risk.
#2- You say "...a grand total of 6 strokes were ASSOCIATED with chiropractic treatment (keep in mind this says nothing of causation)..."
Are you implying that manipulation DOES NOT cause strokes? Are you denying the possibility that manipulation can cause strokes?
Let's revisit your "beauty parlor stroke" data that you were so happy to wave around- is the fact that a person had a stroke PROXIMAL to a visit to the beauty parlor prove CAUSATION, in your mind? Couldn't it just be that the person was ALREADY stroking when he/she visited the beauty parlor? Or, in other words how do you know that the beautician CAUSED the stroke? ASSOCIATION does not mean CAUSATION.
So do you see how the games you're playing are easily turned against your argument?
DOES spinal manipulation of the cervical spine present a risk for stroke? Undoubtedly. Is this risk small? Very. But, there is a risk. These facts will likely not be challenged by medical professionals, least of all, I would think, by most PTs.
Now, the issue should be framed thusly: is there a methodology in place for the chiropractic profession (and other manipulative therapists) to try to reduce unecessary complications?
Case in point- many chiropractors manipulate ASYMPTOMATIC necks, in the unproven belief that there is a preventive effect for the patient. Now, in these cases, where there is simply NO reasonable benefit to be seen, there STILL exists this (small) risk of strokes. The risk/benefit ratio in this case is horrible. I would like to know- what is the chiropractic profession doing to try to eliminate this practice? Is there even one chiropracic "leader" who is willing to come out on the side of reasonable practice here?
Next, what is the chiropractic profession doing to study this phenomenon? What is the chiropractic profession doing to develop better screening methods to identify those patients who might be at risk for stroke? What is the chiropractic profession doing to responsibly address the very real risk of strokes from manipulation?
Unfortunately, the answer to all the above questions is, not a heck of a lot. There is no adverse events reporting system in place, or being developed. There is no research being conducted by chiropractors do develop accurate pre-manipulation tests to reduce the risks.
This lack of movement on the part of the chiropractic profession, coupled with the constant derision, by chiropractors, of studies performed by medical researchers, makes it appear that the chiropractic profession has no real interest in addressing this topic in an honest manner.
It is this "denial" attitude that puts chiropractors in an indefensible position. It is this "circle the wagons" mentality that make chiropractors seem collectively unwilling to honestly appraise the situation.
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Re: Chiropractic madness!!!!!!!!!!!! - April 12, 2002 1:59:00 PM
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ChiroGuy
Posts: 63
Joined: January 24, 2002
From: Toronto, Ontario, Canada
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Wow, lots to respond to.
First, to SJBird5. You are partially correct in your first response to my hairdressing comments. A case that occurred several years ago in Saskatchewan involved a woman having a stroke at the chiropractor’s clinic shortly after receiving a cervical manipulation. The chiropractor was found not liable.
The part of your comment that I have concern with is that you think because a woman stroked out in the presence of a chiropractor, he/she must be responsible. This is a common error many people (even researchers) make, and may lead to some of the statistics that show very high risks of treatment. Since 10-15% of the Canadian population sees chiropractors and Stroke and Heart Disease is the leading cause of death, studies which link a patient EVER having seen a chiro to cause of death have an inherent and fatal flaw. Even studies which limit time periods of the events to 2 days may have some, though admittedly much less, room for error. I have one professor who had a new patient come into his office (having never seen a chiro before or been manipulated) that had a stroke right in his waiting room before even seeing the Dr. Had this man’s stroke occurred 20 minutes later, ie. after being treated, the chiropractor would be automatically accused of causing the man's death. See where I’m going with this? I’m not denying that cervical manipulation can, very rarely, cause VBI but rather that association does not equate to causation.
But I digress; the above point was never my intent for this discussion but since you brought it up I thought I’d mention it. Conversely, the same methodological error must be avoided when researching the number of strokes caused by placing a person's head in the hair-washing position.
I’ll be responding to everyone if I get time, so be patient!
Chiroguy
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Re: Chiropractic madness!!!!!!!!!!!! - April 14, 2002 8:56:00 PM
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ChiroGuy
Posts: 63
Joined: January 24, 2002
From: Toronto, Ontario, Canada
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Drew,
Thanks for your interpretation of what I wrote; you’re correct that my intent was not to link the two practices. I merely wanted to illustrate an activity of daily life that many people engage in without concern (or knowledge) of the risks involved. Sorry if I came across as trying to vilify hairdressers or shift blame of strokes to them.
Thank you for your support for my opinion that the public should be educated with facts so that they can make decisions about their lives. I think it’s about time we put an end to scare tactics (all fields are guilty of this, mostly for self-serving or uneducated reasons) and tell people about true benefits and risks of treatments. I’m not sure, however, that I understand what you are getting at when comparing different responsibilities of hairdressers and chiropractors. The fact is that it is the very motion of extending and twisting the head back into a hairwashing position that causes the VBI that may lead to stroke. This is very similar to the case of cervical manipulations. Interestingly, research has shown that there is less strain put on the vertebrobasilar artery during neck manipulation than in many activities of daily life. Work done by Dr. G. Kawchuk at the University of Calgary has shown that the vertebral artery experiences approx. 6-8% force required for tearing during cervical manipulation. As you said Drew, some people have vascular problems which might put them at more risk.
I’m not sure what the rest of your complaints pertain to, but at my college we are extensively trained in recognizing signs of VBI and testing for a susceptibility to it (although the tests are notoriously poor when tested scientifically). We admit and recognize risks are involved with treatment, and attempt to minimize the possibility of such an event from occurring. As with any other field of medicine, we cannot predict all outcomes but attempt to practice with due diligence. Before a patient is ever treated, we completely inform them of possible risks involved with treatment, including stroke. If the patient does have an adverse reaction to treatment, we are completely trained with how to deal with it (including what emergency/referral decisions we should make). Do members of the profession get roused and angered by some of the claims made by opponents implying that chiropractic care is dangerous? Absolutely, and with great reason. The same statistics that are misinterpreted and manipulated (no pun intended) to make adjusting seem dangerous should be used to demonstrate the victorious safety of our care.
Can cervical manipulation cause adverse reactions, even death? Without question. Is there any evidence that chiropractic causes any more strokes than the acts of looking over your shoulder to change lanes, having your hair washed, lifting heavy objects, playing volleyball or coughing vigorously? Absolutely not, at least to my knowledge. The frustrating thing is that the risks of manipulation are often not put into perspective and the public gets the impression we are dangerous. This is why chiropractors are often defensive.
I’m not sure where you are getting this impression that the profession is trying to somehow avoid talking about true risks involved – conversely we are desperately trying to inform the public of exactly how low they are. Please explain what you are referring to with your closing comments.
Thanks,
Chiroguy
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Re: Chiropractic madness!!!!!!!!!!!! - April 17, 2002 4:40:00 PM
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Wisecracker
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I have stayed out of the fray for abit, but would like to add my thoughts as a practicing DC with other graduate degrees (academic), and a few prospective studies performed and accepted.
Mine is not a profession of great thinkers, as a whole (or on average). This is the distressing truth. Yes, there are exceptional intellects in the profession, but they are few and far between. More like statistical confounders. We are more commonly lead by charismatic religous zealots. These zealots could care less about truth, they could care less about things such as regression of the mean, observational bias, etc. They lead by emotion, which is a poor substitute for cognition.
Our leaders do not understand scientific method. They do understand public relations. And that's what the profession gets lots of, PR in place of evidence based practice.
With that said, SMT to the C-spine performed on an appropriate candidate for a limited trial has an efficious basis. Is there risk involved? Indeed. Can the risk be minimized? To an extent, but that has some level of controversy. How much risk is involved? Unknown, though it is a relatively small risk possibly 1:600,000 to 1:1,500,000, though this is conjecture at best. Of course, no matter the level of risk it is completely unacceptable to perform SMT to the C-spine on asymptomatic patients.
With this said, I believe that the Canadian Neurologist's call to action was not an altrustic public health warning. I do not know if other agendas drove the call to post warning labels on DCs, but in other instances of risk from a procedure this is dealt with in the informed consent portion of the patient encounter. I believe this is a more appropriate recommendation. But of course I am biased in my view.
Instead of making a statement/rebuttal based in truth, such as there is a small risk of complication secondary to SMT to the C-spine, I work in a profession that is more apt to respond with smoke and mirrors. Just as it did. It's a pity, because manual medicine (what I believe the best of the DC model operates in) has a role to play within the healthcare system.
I await the flames...
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Re: Chiropractic madness!!!!!!!!!!!! - April 18, 2002 2:22:00 PM
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researchdoc
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Wisecracker-
Thank you for joining the fray. Rather than flames, let me say that I think yours is a reasonable position.
Most reasonably, you stated that performing SMT on asymptomatic patients is unacceptable (in light of current evidence). This, unfortunately, is a postion not shared, apparently, by those in positions of leadership in your profession. This practice needs to be STOPPED unless and until credible evidence showing a benefit of this practice can be produced. It is not enough for individual chiropractors to denounce the practice- the leaders must move to stop it. I have seen nothing to suggest that they are interested in doing so.
As for the risk level that you describe, this is possibly accurate, but just as possibly not. Therein lies the problem- chiropractors don't even accurately know WHAT the real risks are, yet they scream and cry when neurologists try to study this phenomenon.
I have seen utterly pitiful studies from the chiropractic profession lauded by the likes of the FCER- notably that study by Haldeman in which they looked at malpractice claims for their stroke data, and used an "estimate" of the number of cervical manipulations performed to arrive at an estimate of 1 serious complication per 5.85 million manipulations- this study is on the FCER website. It is less than useless. Yet A. Rosner (director of the FCER) has the cajones to accuse the Canadian neurologists of being biased? Puuuhhhhlllleeaasssee!
The chiropractic profession has some gall to come out and try to villify the neurologists who are trying to study this issue. Perhaps their "non-altruistic" motive, as you put it, is actually altruistic after all- they are the ones who are left to clean up the "small risks" that become big problems in the form of injured and dead patients. And really- is it fair to question their motives when the chiropractic profession flat out denies the risk (I actually read an article by Chris Kent, DC, which, in a disgraceful misuse of statistics, actually suggested that manipulation PREVENTS strokes)? Who's gaining more in this scenario? What are the neurologists GAINING by this "non-altruistic" agenda? What are chiropractors gaining by denying it? Who has more to gain, really?
At this point, informed consent is a necessary thing to do, and I see some movement in this direction by the chiropractic profession to require it. But beyond that, the I see little desire to tackle this issue in an intellectually honest manner by chiropractors. There needs to be accurate risk assessment studies performed- but this can only be done with cooperation between the chiropractic profession and the medical profession, in a pro-active manner, not a defensive, reactive one. Also, cooperation might lead to defining the at-risk population, so that cervical manipulation can be made even safer than it is.
I would also like to see some definitive studies that show that there is a significant benefit for this procedure, but I guess one thing at a time, right? ;-)
Your post is a reminder that there are reasonable persons in the chiropractic profession. My concern is that there may be too few like you for effective change to occur. We shall see.
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Re: Chiropractic madness!!!!!!!!!!!! - April 18, 2002 3:40:00 PM
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Wisecracker
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I would agree with much of what you have stated. The FCER is far more PR than science. The Haldeman study is of no value. And the real risk of CVA secondary to C-spine SMT is unknown, though I contend it is small. As I think you would agree.
I say that the Canadian Neuros were not alrusitic because of past experiences. To not believe or acknowledge that there have been problems in how some in the medical profession have interacted with the chiros is naive. That is not to take away from the disgraceful effluent spewed forth by some of the chiros towards the medical profession. But, not only have there been attitudes dismissive of chiros by the medical profession, there have been instances of outright deception to steer opinion.
For example, Hufnagle's 1999 paper in the Journal of Neurology titled Stroke following chiropractic manipulation of the cervical spine. Sounds like a chiropractic paper. Retrospectively, 10 subjects present for either neck pain and/or headache. The subjects had SMT to the c-spine, with dire consequences either vertebal or carotid artery dissection. I don't know about your region, but where I am this study got alot of play in the laymedia. The problem was that the study was misleading. The people performing the SMT were either orthopedists, PTs or massage therapists. No chiropractors. I'm not suggesting that the SMT would have not caused CVA if performed by a DC (though it would have been interesting to know the level of manipulative training the other parties had acquired prior to the fateful event). But wouldn't the title been a tad more accurate to state Stroke following manipulation to the C-spine? or some variation?
That is why I have a tendency to question not only the message but the agenda of the messagener (and any financial ties).
So, though I continually have to overcome my initial defensive posture, I still believe that there is validity to questioning the agenda of those involved.
With that said, I believe that the stroke subject should be looked into by a consortium of nonpartisan researchers with varied backgrounds. Of course, the truth is what we seek, unfortunately someone has to write the paper.
Looks like I've rambled a bit, sorry am a little tired, I'll edit later.
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Re: Chiropractic madness!!!!!!!!!!!! - April 18, 2002 5:42:00 PM
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researchdoc
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The thing is, Wisecracker, Hufnagel is not associated with the Canadians. He and his colleagues are from Germany. Implications of conspiracies will only get your argument so far. At some point, these conspiracy theories break down, and honest assessment must follow.
The fact is, neurologists are seeing stroke victims in their practices, and these neurologists are "for some reason" attributing these strokes to chiropractic manipulation. So, they are looking into the question, in most cases, quite objectively and without evident prejudice.
Chiropractors, on the other hand, react to these studies with polemics and vitriol, accusing the neurologists of being "out to get" them, and other such nonsense. It just doesn't work, outside the pages of Dynamic Chiropractic and The Chiropractic Journal. Again, I cannot clearly see what the supposed gain for the medical doctors is here, that they would go about deliberately misrepresenting the data. In contrast, the gain for the chiropractors is glaringly obvious.
What is also interesting to me is, how chiropractors so readily excuse or downplay the miniscule risk of adverse effects with SMT, while at the same time, raising holy hell about the (similarly small) risk of vaccinations. This in the face of the overwhelming evidence of efficacy of vaccinations and the relative paucity of evidence in favor of cervical SMT.
I know, that is a red herring, and I apologize. It is just an interesting duplicity I have noticed.
Getting back to your points, it is your right to question the motives of the medical profession, but just understand that sooner or later, the data becomes compelling in spite of the motives involved. If the chiropractic profession cannot generate accurate credible scientific data to refute the studies, and instead relies on poorly done "PR" studies and verbal attacks to make it's case, it will lose.
BTW, I will look into the Hufnagel paper again, as it's been awhile since I have read it. Understand, however, that in Germany, physiotherapists and other manual therapists are highly trained in manipulation- perhaps as well trained as chiropractors in the US. So at some level, the charge that these people are somehow less able to deliver a safe manipulation falls flat. As for your complaints on the title of the paper, you should take that up with the authors (You can email Hufnagel here: a.hufnagel@uni-essen.de). One would suppose that if the results of the study were more positive for manipulation, chiropractors would be much less objectionable to the use of the term.
;-)
No doubt, by the way, that there exists bad blood on both sides of the issue. However, the reactions I've seen from the likes of Rosner, Kent, and Terry Rondberg, DC, contrasted with the reserved approach of the medical researchers, makes it very hard to sympathize with the chiropractic perspective. Just one man's opinion, of course.
I'm curious, Wisecracker- what are your thoughts on how one might design a study or studies to investigate this question of risk of cervical SMT? I have been thinking about this for some time, and would appreciate your thoughts.
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Re: Chiropractic madness!!!!!!!!!!!! - April 19, 2002 3:36:00 AM
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Sebastian Asselbergs
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Just a little reminder: "manipulation" is seldom, if ever, precisely defined in any of the research and studies into the techniques. This includes studies by chiropractors. This makes those studies virtually invalid from the start. Hardly any study mentions directions (rotation, linear, combined movement etc)of manipulation, or whether traction was part of it - forces were inadequately described as well.
(See my previous post on this thread on the review article)
This ivalidates both pro- and anti-manipulation studies.
Sebastian
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Re: Chiropractic madness!!!!!!!!!!!! - April 22, 2002 4:53:00 AM
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researchdoc
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Wisecracker-
Upon reviewing the Hufnagel paper, I don't see the big problem. Yes, they used the term "chiropractic" manipulation, but they seemed to do so not as a method of impugning chiropractors, but rather to define the type of manipulation studied, i.e. HVLA. (Sort of like using the term "Kleenex" instead of "facial tissue".)
I do not see in that paper where their conclusions were unwarranted or not applicable to the chiropractic profession who, as we know, are the major providers of HVLA manipulation. I think the charge of bias and suspicion regarding their motives is misplaced in this instance.
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Re: Chiropractic madness!!!!!!!!!!!! - April 24, 2002 10:49:00 AM
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researchdoc
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Chiroguy-
Could you please supply the specific reference from which you got this information:
"Work done by Dr. G. Kawchuk at the University of Calgary has shown that the vertebral artery experiences approx. 6-8% force required for tearing during cervical manipulation."
Thanks in advance.
Also, you say that "The frustrating thing is that the risks of manipulation are often not put into perspective and the public gets the impression we are dangerous."
I will respond that the public does not, apparently, seem to think you are dangerous, as they make many visits to your providers for care. However, what IS dangerous is the application of a procedure that has little benefit to offer while having at the same time definite risks.
What I am referring to here is the manipulation of asymptomatic cervical spines for the purpose of "wellness" or "prevention". This practice needs to be stopped by your profession, if you are to take the risks seriously. Otherwise, it appears that your profession chooses to cavalierly ignore the risks for the pursuit of what? Money, perhaps?
Well, whatever the motivation, THIS is what needs to be "put into perspective", as you say.
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Re: Chiropractic madness!!!!!!!!!!!! - April 24, 2002 2:20:00 PM
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Wisecracker
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My apologies for my delay in returning to the forum thread. My previously stated tiredness (last post) was actually influenza. One of the pesky strains that wasn't in the fall flu shot. Still not up to par, but at least now 2 synapsis are firing.
Back to the subject at hand. I never meant to imply that Hufnagel et al were in anyway associated with the Canadian neurologists. Nor am I a proponent of some vast conspiracy in this instance. My point (sloppy as it were) was that nothing was added to the paper in adding the descripter CHIROPRACTIC in the title. That's all.
I'll try now to make another point and shed some of my previous sloppiness. Ernst's stroke paper correctly points out that looking only at published cases in forming a numerical risk assessment is biased towards a low risk (Terrett, Haldeman). But he then cites the two neurologist's surveys as "evidence" that the frequency is higher without addressing the inherent bias in such data gathering. Is this a chiro conspiracy issue? No. It's just sloppy logic. And what chiros get beat-up on all the time for, though more deservedly in most cases.
Thus, I believe it is important to evaluate thoroughly all issues. Including alliances and agendas of those involved.
As to your "red herring", I would agree that if my brethern understood risk analysis, the efficacy of vaccination would become a non-issue. Though, I still question the neccessity of the varicella vaccine in the non-immunocompromised population. Of course, keep in mind I have no training or education to have substancial knowledge to truly question this.
Back to point, yes, I've already agreed that my profession lacks much of the required cognitive facaluties to critically evaluate the literature, impliment solid research, or to do much more than rah-rah the spin from the chiro "intelligenista".
Finally, to answer your question concerning the research design of C-spine SMT and stroke (and yes it is a travesty to patient welfare to perform SMT to an asymptomatic patient in the name of "wellness") I would first want to know if I have unlimited resources for my study, or am I hindered by the real world?
I think I'll go rest now, it appears from my raving here I'm not as functional as I thought.
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Re: Chiropractic madness!!!!!!!!!!!! - April 24, 2002 4:08:00 PM
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researchdoc
Posts: 34
Joined: March 29, 2002
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Wisecracker-
Thanks for your reply.
Of course we are hindered by the real world. There exists little opportunity, I think, in the real world, to develop a study that would prove causation in the manipulation/stroke question- as is often the case in procedures where the risk is so small. So we are left looking for pragmatic studies from which to generate data and conclusions. I am curious as to, within the context of the real world, what types of studies chiropractors would consider as valid?
Regarding Ernst, I am not sure if you are referring to a specific paper. You say "Ernst's stroke paper"- he has published in CMAJ and most recently the MJA, as well as others. Nevertheless, I do not see where the bias is coming through in his papers that would make me question his motives or agenda.
For instance, in the CMAJ, he says: "What is the message for primary care physicians? On the one hand, there is little evidence to demonstrate that spinal manipulation has any specific therapeutic effects. On the other hand, there is convincing evidence to show that it is associated with frequent, mild adverse effects as well as with serious complications of unknown incidence. Therefore, it seems debatable whether the benefits of spinal manipulation outweigh its risks."
[URL=http://www.cmaj.ca/cgi/content/full/166/1/40?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=ernst+e&searchid=1019691167292_3796&stored_search=&FIRSTINDEX=0&journalcode=cmaj] [URL=http://www.cmaj.ca/cgi/content/full/]http://www.cmaj.ca/cgi/content/full/[/URL]
166/1/40?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=ernst+e&searchid=1019691167292_3796&stored_search=&FIRSTINDEX=0&journalcode=cmaj[/URL]
Personally, I think this is about as good as you should expect from a non-chiropractic "advocate". While he goes a little farther than I would in minimizing the benefits (I personally am mainly against the use of SMT in asymptomatic patients), he has valid points here from an evidence-based perspective.
In his MJA paper, he concludes "... serious complications of cervical spine manipulation appear to occur regularly. Their incidence is essentially unknown and should be established as a matter of urgency through adequately designed investigations".
[URL=http://www.mja.com.au/public/issues/176_08_150402/ern10520_fm.html]http://www.mja.com.au/public/issues/176_08_150402/ern10520_fm.html[/URL]
This seems to contrast with your statement that "... he ... cites the two neurologist's surveys as "evidence" that the frequency is higher...". I haven't seen where he is claiming "evidence" to any particular level of risk, but rather he seems to be taking a conservative approach to the data.
Now, again, not being sure which paper you are referring to, in the CMAJ, Ernst references the Ontario study, which was not a survey but actually a case-control study. Regarding that study he says: "The authors concluded that these results were 'consistent with a positive association in young adults' but warned that potential sources of bias have to be considered."
Sounds pretty conservative and fair to me.
Of the survey study that his group performed, he says: "Sadly, survey data are never free from bias, and we would certainly not claim that our results are conclusive."
This doesn't sound to me as if he is claiming "evidence" here.
From a "comment" in Stroke, he states: "The incidence of life-threatening complications, however, is unknown, and previous estimates have all been based on assumptions which may or may not be true. The true risk might well be minor, but in matters of patients’ safety we require certainty. The only logical conclusion is that large, prospective studies are needed which are designed to generate reliable incidence figures even of rare events."
Sounds pretty fair to me. I am curious as to how he thinks such a study could be undertaken. Such a study would necissarily require the interprofessional cooperation of the chiropractic and medical profession.
Anyway, thanks again for the reply. I have no real beef with anything you say. I hope you get to feeling better.
[This message has been edited by David Adamczyk (edited October 08, 2002).]
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Re: Chiropractic madness!!!!!!!!!!!! - October 3, 2002 12:06:00 PM
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PC-CRACKER
Posts: 2
Joined: October 2, 2002
From: Kailua-Kona, HI
Status: offline
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Chiropractors are offended by the assumption that they are subordinate to your average MD or DO. Their educations are comparable with the exception of pharm,surgery and a residency(should be added for DCs). But you have to remember that the Chiropractic profession tries to utilize drugless treatment whenever possible and appropriate. It doesn't mean that a DC doesn't know how to manage non-subluxation related illness. It just means that we can't manage the pharmacological treatment of said illness. I have been PCPhysician to many patients. My definition of Physician is one that even if they can't directly treat with their primary mode of therapy, they direct the patient to the appropriate provider(not necessarily specialist). I consider a GP (MD/DO) a specialist in the arena of pharm treatment of disease.
Yes, some DCs are not qualified to act as a PCphysician. This does need to be addressed in continuing ed and certification. On the other hand some MDs/DOs are not qualified to be PCphysicians either.
I don't know enough about the DPTs education to comment. Maybe you could enlighten me.
PCC
[QUOTE]Originally posted by Andrew M. Ball MS MBA PT:
SJ,
I don’t mean to be patronizing, but welcome to the discussion. Sounds like you went back and read the previous postings in this thread about the differences between a PCpracitioner and a PCphysician. Your recent experiences certainly have given you the tools to now tell the difference. I dare say that we (the collective we) DC's and PT's on this forum belive that both DC's and DPT's are qualified to operate as PCP's, provided that means PCpracitioner and NOT PCphysician (under the definitions that follow).
With the exception of maybe one or two DC's, I think there is general consensus here.
Your statement, "If wellness is truly an issue, why not have physician assistants or nurse practitioners handle that kind of stuff?" Demonstrates an apparent revelation on your part, and one that I've been trying to get across for some time now. You seem to have articulated it better though. Anyway, role of the PA and NP's is exactly what the APTA has in mind for DPT's . . . within, of course, certain scopes of practice. This is what is meant by a PCpracitioner. This is NOT what is meant by PCphysician.
I have no problem with DPT's or DC's as PCpractitioners. Some DC's, however, don't seem to know the difference and are using PCP to describe both. When most DC's talk about a desire to be a PCP, they usually mean PCpracitioner . . . and we as PT's should support that. Their problem is that by not well defining what they mean by PCP, some of the more loopy of their ranks, (I'd assume the non-members of their professional association), are under the incorrect assumption that PCP for DC's means truly replacing MD's with DC's as PCphysicians. Even Dr. Peterson, who came on this forum fighting rather loudly for respect as a PCP . . . turned out to largely mean PCpracitioner.
There are a few, and I'd suggest that they tend to be ill-informed ones on the outskirts of thier profession, that actually mean for PCP to mean PCphysician. Dr. Peck, for example, is either one of these people, or didn't read and understand postings leading up to his regarding the difference between PCpracitioner and PCphysician.
For reasons described above, I don't think that most chiropractors actually mean PCphysician when using that terminology. The few that do, are quite obviously out of their minds. When the issue is debated professionally, I've found that most DC's agree that diagnostically trained DC's and DPT's alike are capable of operating as PCpractitioners (like OD's, Podiatrists, PA's, NP's, etc), and most don't mean --- nor want the responsibility of being --- a PCphysician.
As for your final comment, I’m not sure what your injury was, but I’ve got to side with the DC’s as being competent to act as a Pcphysican here. Why would a DC, working as a physician extender like a PA or NP, not be an appropriate person to see? Suppose you had just banged up your shoulder a bit. An appropriately trained DC could take an X-ray (or order one) and determine weather or not the injuries fell within his or her scope of practice. A DPT could do the same. Like a PA or NP, either DPT or DC would have to have their diagnosis and services reviewed and signed off on by a real PCP, a PCphysician, within 48 to 72 hours (depending on the state).
This was basically the model of PCpracitioner loosely overseen by a PCphysician. Worked well for you with a PA or NP in that role. Why not use a DC or DPT for issues that appear to be musculo-skeletal in nature?
What I can't understand is, DC's have done quite well operating on the fringe of the healthcare industry. They have escaped peer-review and evidence-based review of the effectiveness of their treatments beyond natural history or with relations to other treatment paradigms. Why subject the profession of Chiropractic to external review under which it (like physical therapy) can't withstand?
Furthermore, DC's already operate in a fairly autonomous manner. Why give that up in order to re-enter the healthcare enviroment as a PCpracitioner? It elevates thier respect within the healthcare environment by placing them on par with other professions emerging as PCpracitioners (OD's, Podiatristists, DPT's, etc.), but submits to a subordinate position just below the PCphysician --- the MD or DO.
DC's have been at feud with MD's for so long, that I've got to wonder if thier quest to be a PCpracitioner is really what they belive to be a stepping stone --- DC's as truly PCphysicians atop the Healthcare Pyramid.
I was snooping around on ChiroWeb this morning and couldn’t resist responding on thread where a DC basically suggested to the mother of a non-ambulatory 22 month old child who had a “stroke” in utero, that Chiropractic should be the treatment mode of choice for this “balance problem.” No suggestion of seeing a physical therapist for neurodevelopmental therapy and strengthening/control of lower trunk musculature, orthotic intervention, or perhaps PWB-TT. No suggestion that a neurological, genetic, or perhaps metabolic evaluations may be good ideas. Heck, no one even questioned what the child WAS doing developmentally. Nope, it’s all in the spinal subluxation apparently. How irresponsible.
It's not just lack of compotence in extra-subluxationar dignosis repeatedly demonstrated on the part of many DC's. Until DC's can address all of the primary healthcare needs of the patient, from birth to death, that's simply not realistic. It's the same reason why DPT's will never be PCphysicians either.
Andrew M. Ball, MS, MBA, PhD(c), PT[/QUOTE]
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