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"…we surely stick out like a sore thumb among professions which claim to be scientifically based by our unrelenting commitment to vitalism. So long as we propound the 'one cause, one cure' rhetoric of Innate, we should expect to be met by ridicule from the wider health science community. Chiropractors can't have it both ways. Our theories cannot be both dogmatically held vitalistic constructs and be scientific at the same time."

Joseph Keating Jr, 'The Meanings of Innate', Journal of the Canadian Chiropractic Association, 46,1 (2002), p.10.

 

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“Some chiropractors employ manipulation in the same way physical therapists, M.D.s and D.O.s do – as a physical therapy for patients with back or neck pain who have been conventionally diagnosed and found to be appropriate candidates for this therapy. However, chiropractors also use the term “spinal manipulation” as a synonym for “spinal adjustment” which, in their unique vocabulary, is a treatment for the ubiquitous and nonexistent subluxation. Only chiropractors use the term in this manner because only chiropractors believe the chiropractic version of the subluxation exists…Not surprisingly, chiropractors cannot agree on a definition for their subluxation, how to diagnose one, or its clinical significance. They can’t even agree on a name for it – it’s variously called the vertebral subluxation complex, manipulable lesion, spinal lesion, joint dysfunction, and so on. Nor can they agree on its role in chiropractic – large and unremitting intramural battles have been fought over the subject. Nevertheless, chiropractors daily tell patients that they are suffering from subluxations which must be corrected at the risk of ill health. Again, one means of correction is the chiropractic “adjustment,” which chiropractors also refer to as “manipulation.” If chiropractors are this confused, then one can well understand how the writers and editors of NCCAM’s [National Center for Complementary and Alternative Medicine] website could be confused, but it’s time to set the record straight. The correction of subluxations via a spinal adjustment/manipulation is not the same as the use of spinal manipulation by physical therapists and other health care providers as a means of alleviating back or neck pain. While it is true that a chiropractor might “find” a subluxation and claim it is the cause of a patient’s pain, this is not a legitimate diagnostic method nor is its correction via an adjustment/manipulation a legitimate therapy for the patient’s pain. NCCAM does its readers a real disservice in failing to explain this critical difference. As it stands, readers may be left with the incorrect assumption that a chiropractor’s use of adjustments/manipulations to correct subluxations is a useful therapy for neck or back pain. This is especially important because some chiropractors have intentionally tried to exploit the efficacy of manipulation for back pain as proof that chiropractic “works.” They have also falsely claimed that they are more proficient at, and safer in performing, spinal manipulation than other practitioners, to the point of trying to use the political process to prohibit physical therapists from employing manipulation.”  Jann Bellamy, Science Based Medicine (26th July 2012)

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…I came across a hilariously paranoid post by a chiropractor calling himself J. C. Smith (JCS), who runs a website called Chiropractors for Fair Journalism…The article starts with the typical canards laid down by chiropractors about how horrible the American Medical Association is and how it supposedly tried to shut down chiropractic (as though that were a bad thing), referring to the AMA as a “medical mob” and referred to Morris Fishbein, MD, former director of the AMA as a “longtime medical godfather” and the “medical Mussolini.” JCS then equates opposition to the pseudoscience and quackery that underlie chiropractic with “bigotry”…Never mind that chiropractic is unscientific. Never mind that there is no such thing as a subluxation. Never mind that it’s nonsense that chiropractic is superior to medical care for spinal disorders…” Orac at Respectful Insolence (3 July 2012)

Part 2:  A chiropractor strikes back at the Institute for Science in Medicine…again

“In the end, this followup post attacking ISM is risible in the extreme, relying primarily on tu quoque arguments, emphasizing harm that conventional medicine can cause while not balancing it with the good, personally attacking people…and in general using the same old fallacies favored by cranks and quacks.”  Orac at Respectful Insolence (20th July 2012) [Includes a critical assessmement of ‘death by medicine’]

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“…experts debated the safety and effectiveness of spinal manipulation for neck pain in the pages of the British Medical Journal [BMJ 2012;344:e3679].  The debate featured academics, some of whom said that spinal manipulation should be abandoned as a treatment for neck pain, and some who disagreed saying that it is a valid treatment that patients like…

Should we abandon cervical spine manipulation for mechanical neck pain? Yes  [Full text PDF]

Given the equivalence in outcome with other forms of therapy, manipulation seems to be clinically unnecessary. The potential for catastrophic events and the clear absence of unique benefit lead to the inevitable conclusion that manipulation of the cervical spine should be abandoned as part of conservative care for neck pain. In the interests of patient safety, the regulatory and professional bodies associated with professions that use manual therapy should consider adopting this as a formal policy.

Benedict M Wand, Peter J Heine, Neil E O’Connell.

Should we abandon cervical spine manipulation for mechanical neck pain? No  [Full text PDF]

…when risk, benefit, and patient preference are considered, there is currently no preferred firstline therapy, and no evidence that mobilisation is safer or more effective than manipulation. Thus, the identification of safe and effective interventions for neck pain remains a high priority. We say no to abandoning manipulation and yes to more rigorous research on the benefits and harms of this and other common interventions for neck pain.

J David Cassidy, Gert Bronfort, Jan Hartvigsen.

…Both articles are based on the professional opinion of the authors, who each presented evidence supporting their viewpoints. They are not systematic reviews and it is unclear whether all evidence relevant to spinal manipulation has been considered. No firm conclusions for or against spinal manipulation can be made based on these opinions alone…People with persistent neck pain should consult their doctor and discuss the treatment options that would be appropriate for them...The debate, although loosely defined, appears to focus on spinal manipulation of the neck by chiropractors, rather than by osteopaths or both…These articles were designed to stimulate debate in a controversial area rather than to offer conclusions.”

NHS Choices review (8th June 2012)

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"We only see what is being published and that can only be the tip of the iceberg," said (Edzard) Ernst. "Some neurologist sees a stroke and he finds out that this was associated with chiropractic – in 99.9% of cases he won't publish that." Ernst said the under-reporting of adverse effects meant decisions about the best course of treatment for a patient would be made difficult. "Therapeutic decisions ought to be taken not on considering the effectiveness alone but also you have to have effectiveness as a balance with the potential for harm. You have to do a risk-benefit analysis. When you under-report risk, this cannot possibly be done robustly." Alok Jha, The Guardian (14th May 2012)

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"Within hours of the publication of this new US study [Bronfort G, Evans R, Anderson AV, Svendsen KH, Bracha Y, Grimm RH. Spinal manipulation, medication or home exercise with advice for acute and subacute neck pain. A randomised trial. Ann Intern Med 2012; 156:1-10], the world of chiropractic celebrated it as a vindication of chiropractic spinal manipulation. Its aim was to “to determine the relative efficacy of spinal manipulation therapy (SMT), medication, and home exercise with advice (HEA) for acute and subacute neck pain in both the short and long term”. Because neck pain is such a common problem which is often difficult to treat, this study did indeed seem important…At first glance, this seems to be a rigorous piece of research. At closer scrutiny, however, the flaws of this study become fairly obvious…I therefore fear that this study merely shows that TLC and non-specific effects can strongly influence symptoms such as pain. If we consider the high costs of regular SMT versus the negligible expense of HEA, the latter would probably turn out to be preferable. If we finally factor in the potential for harm, the balance decidedly tilts towards HEA. Exercise is virtually risk-free, whereas SMT results in transient adverse effects in about 50% of all patients; in addition, it is associated with several hundred severe complications including deaths." Edzard Ernst, The 21st Floor (1st May 2012)

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A study by American neurosurgeons adds to evidence suggesting chiropractic can damage arteries supplying the brain...The conclusions of the American neurosurgeons in their recent paper speak for themselves: “Chiropractic manipulation of the cervical spine can produce dissections of the cranial and cervical segments of the vertebral and carotid arteries. Given the popularity of chiropractic treatment, the incidence of this phenomenon is most likely underreported. These arterial injuries can be severe, producing adverse neurological sequelae and even death (including 31% of patients in this series). Consequently, aggressive endovascular and surgical techniques may be required to restore vessel patency and to preserve neurological function." Professor Edzard Ernst, The Guardian (27th April 2012)

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Conclusion: Animal chiropractic and the veterinary chiropractic courses scrutinized here mix science, pseudoscience and fantasy and make no visible effort to show which is which. They give biased information and refer to more or less irrelevant articles to make the courses look serious and credible. Many of the methods taught lack evidence as well as plausibility and are clearly outside the realm of medical science. We found no evidence for the use of animal chiropractic in veterinary medicine. Ragnvi E. Kjellin, DVM, and Olle Kjellin, MD, PhD, Science Based Medicine (16th March 2012) [NOTE: This article was submitted to a series of veterinary journals, but none of them wanted to publish it.] 

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Author: Smith JC. REVIEW: "This book is focused on the unfortunate legal battle between the American Medical Association (AMA) and the US chiropractic profession. It could be an interesting historical exposé but, unfortunately, JC Smith spoils it thoroughly by his entirely one-sided, biased view and inflammatory language. Smith goes not one but several steps too far and thus loses all credibility. For instance, he repeatedly compares the ‘medical lynch mob’ to Nazis and extreme racists: ‘Just as the Nazis used the Big Lie to undermine the image of Jews, so did the AMA use its own version of the Big Lie to defame the chiropractors’ (p. 132). Elsewhere, Smith states that the actions of some medical professionals in Florida were ‘clearly reminiscent of the days of racial desegregation in the South’ (p. 179). This is a great shame, not least because the tensions between the two professions would deserve a scholarly evaluation. I suspect that a sober analysis would have put the clinical evidence in the centre; an aspect that Smith avoids almost entirely. The tensions, I fear, are not between two groups fighting over the same patients, but between one group believing in science and evidence and the other having very little more than aggressive promotion. As it turns out, this book is not an analysis of a 130-year-old conflict but provides a wealth of misguided concepts; it is also a rich source for rampantly paranoid ideas that sadly still exist in the chiropractic profession.” Edzard Ernst, Focus on Alternative and Complementary Therapies [FACT] (March 2012)

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“A chiropractor who defends a device condemned by doctors as nothing more than ‘a stick that goes click’ [an Activator instrument] sits on the tribunal that is supposed to protect the public from shonky operators. The revelation is a further blow to the credibility of the chiropractic industry and its highest professional bodies, says the Friends of Science in Medicine — a lobby group of more than 400 doctors, medical researchers and scientists.” Australian Doctor (21st February 2012)

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“Chiropractic’s problem is that subluxation based chiropractors are not only deluding themselves, they are indoctrinating patients into believing in a purportedly dangerous mythical entity, and that without regular adjustments, patients will not only fail to reach their full potential, they will likely suffer serious health problems…Escaping from the dogma house will require extraordinary cooperation amongst all aspects of the profession. Organizations such as the World Federation of Chiropractic and all major chiropractic associations will need to agree upon and adopt a position statement identifying the chiropractic subluxation as an historical construct that remains a hypothesis, which cannot form the basis for patient care until and unless there is a body of scientific evidence to support it…The position statement will need to be backed up by these organizations incorporating and enforcing appropriate statements into their ethical codes. Further, educational accrediting bodies will have to modify their standards to clearly state that subluxation is not a concept upon which to base patient care. From this, it follows that chiropractic teaching institutions will be required to restructure their curricula accordingly. These moves will need to be reinforced by the actions of registration boards to deal harshly with the misleading and deceptive advertising on the part of subluxation based chiropractors and the unconscionable conduct that typically occurs therewith. Specifically, registration boards must prohibit the common practice whereby potential clients present to a chiropractor for a musculoskeletal complaint, only to be convinced that they are in fact suffering from subluxation related disorders and require prolonged chiropractic care. Insurance providers will need to alter their rebate guidelines to only provide payment for evidence-based care and to strike from their registers subluxation-based chiropractors. All of this must happen and the public must be informed along the way. Last, but by no means least, it will require each and every chiropractor to be intolerant of the nonsense that is out there. The contract that the profession has with society and its patients is such that, in exchange for a significant degree of autonomy over education, licensing and credentialing, members of the profession are expected to maintain high standards of competence and moral responsibility and interest. If the profession is to gain the trust of the consuming public it must, of necessity, become truly self-policing. Only in this way will chiropractic generate the cultural authority required for recognition as a group worthy of the title ‘profession’. No longer can we cast a blind eye. By our silence we are giving consent.” J Keith Simpson, Chiropractic & Manual Therapies (January 2012) [pdf]

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“The evidence for a high incidence of enlarged blind spots is unconvincing. There is no evidence that blind-spot mapping reflects cortical function or that manipulation can affect the size of the blind spot by altering brain function.” Harriet Hall MD, Science Based Medicine (29th November 2011)

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“Chiropractic neurology appears to me to be the very definition of pseudoscience – it has all the trappings of a legitimate profession, with a complex set of beliefs and practices, but there is no underlying scientific basis for any of it.” Steven Novella MD, Science Based Medicine (16th November 2011)

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“Chiropractic may have reached a new low. A practice in Nova Scotia has started advertising concussion screening for sports teams...This entire process is completely outside the realm of chiropractic. Any patient who is brought to a chiropractor instead of an emergency room for a suspected concussion is at increased risk of death due to delayed onset of treatment and possible misdiagnosis.” Dr. Robert, Skeptical Health (6th January 2012)

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“It is the author’s position that chiropractic is an indefensible profession. It is inherently unscientific. The supposed cause of disease, subluxations, do not exist. And the scientific evidence overwhelmingly finds that spinal manipulation is dangerous and ineffective for practically every application.” Critical review by Dr Robert, Skeptical Health (2nd January 2011)

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A medical doctor puts four questions to chiropractors based on the following evidence: “1. In 2010, a risk-benefit analysis of chiropractic manipulation of the neck found that the risk of any manipulation to the neck is not worth any possible benefit. (Ernst 2010); 2. In 2009, scholarly chiropractors found there is no evidence to support the idea of vertebral subluxation, which is the entire foundation of chiropractic manipulation. (Mirtz 2009); 3. As of now, the best evidence says that chiropractic manipulation, in its entirety, is only effective for certain types of chronic lower back pain, and it’s only as effective as some medical treatment with exercise. (Rubinstein 2011); 4. No systematic reviews have ever found cervical manipulation of the neck to be effective for the treatment of any disease; 5. Systematic reviews have found that “regular” or “preventative” chiropractic manipulation does not promote or in any way improve health, and have found that given the risks associated with chiropractic manipulation, there is no reason to recommend it to any patient. (Ernst 2009); 6. Children do not have fully ossified bones.” Skeptical Health (25th December 2011)

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“Recently there was an excellent, and much read, article on The Conversation entitled There’s no place for pseudo-scientific chiropractic in Australian universities which made the case against chiropractic “medicine” all too well. Dodgy doctors are dodgy wherever they live and are trained…The article, by John Dwyer of the University of New South Wales [see below], made me reflect that in 1998 Dr Bessie Borwein – whom among her many other attributes is my mother – had been involved in a similar, and largely successful battle to stop such bogus or unvetted programs becoming ensconced in Canadian Universities…let me reproduce my mother’s letter – dated April 17, 1998 – when she was an Assistant Dean of Research at the University of Western Ontario – one of Canada’s top medical schools…” Jon Borwein, Professor of Mathematics at the University of Newcastle, New South Wales, The Conversation (23rd December 2011)

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“It’s difficult enough to counter the massive amount of misleading information provided to consumers through the media and online. But the task becomes much harder when tertiary institutes give an undeserved imprimatur to pseudo disciplines by offering them as courses. Central Queensland University (CQU) is the latest to do so, announcing it will offer a Bachelor of Science degree (Chiropractic) from 2012. I’m one of thirty-four doctors, scientists and clinical academics who, in an attempt to protect health-care consumers from the dangers associated with unscientific clinical practices, have today written to the science deans at CQU urging them, as fellow academics, to reconsider this decision…Some chiropractors limit their clinical activities to treat musculo-skeletal problems that cause back pain. There is evidence that shows these manipulations are marginally effective, though they’re unlikely to deliver lasting results, regardless of whether the practitioners are physiotherapists, osteopaths or chiropractors. But a practice limited to spinal area musculo-skeletal discomfort is not what modern chiropractic is all about. Most chiropractors believe and teach that spinal area “adjustment” can be used to treat the vast majority of medical problems.” John Dwyer, Emeritus Professor at University of New South Wales, The Conversation (6th December 2011)

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Australian Medical Association president, Steve Hambleton, has condemned the University of Central Queensland for allowing the teaching of what he and his colleagues describe as pseudo disciplines which ignore evidence and could harm patients: “This course [the new chiropractic degree] puts pseudo science next to science. It actually uses the imprimatur of a university to actually add something to this area of subluxation theory which really isn't supported by evidence which claims that there is innate intelligence which controls all normal body functions and there is guiding energy and some of those people are actually treating children for all sorts of things including bed wetting, asthma, attention deficit disorder. It is very disturbing…there is no doubt that patients will be harmed if they don't get access to the best evidence and the best evidence-based therapy and this is a way of diverting them away from that.” Professor Phillip Ebrall, who is running the course, says the university's critics are basing their argument on ignorance: “Subluxation theory will be taught because it is an emerging theory that is developing an amazing amount of evidence at new levels in support of some of its underlying principles but I am also the first person to say that we still do not understand that fully enough…We don't deal with conditions. We deal about optimising health and wellness…I think it is absolutely fantastic that people know what the university is doing - that the university is open and honest and is presenting what it’s doing with integrity.” Report by Michael Atkin, ABC Today (5th December 2011)

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“Subluxation-based chiropractic remains an integral part of chiropractic practice in North America and Australia, as demonstrated by the uncritical acceptance of articles discussing its implausible diagnostic methods and treatments in peer-reviewed chiropractic journals, its presence in surveys of chiropractic practice in peer-reviewed chiropractic literature, as well as the aforementioned inclusion in chiropractic education.” Jann Bellamy, Science Based Medicine (3rd November 2011)