A Chiropractor Does Research; Haters Gon Hate

The world of “science blogging” can be a daunting one. For some reason, Yvette d’Entremont, aka the SciBabe, is a popular figure within this world. She wrote an article for the online publication The Outline, called “Chiropractors are Bullshit.” The article contained more than a few provable, factual errors, prompting me to write a rebuttal. I posted it on Medium and shared it with a few friends, both in and out of the chiropractic profession. The story was viewed over a thousand times within the first day and I began to receive some positive feedback.

Wow! Brilliant? Talented? Hilarious? I think I like the acoustics inside this little echo chamber of mine. Maybe this is my calling. Maybe I can finally stop ripping people off with pseudo science and become a professional blogger! My parents might FINALLY be able to stop lying to people about what I do for a living.

Unfortunately, this is the internet. And once word got out to the SciBabe’s fans that someone wasn’t happy with her brand of lazy, shit journalism, my reviews became slightly less congratulatory.

Well, it is my first attempt at blogging. I can’t possibly be expected to win everyone over.

Maybe I’m just getting the Food Babe’s hate mail by accident?

Over the next 48 hours, my story would go from around 1000 views to over 5000 views. Turns out Biggie was right about everything.

I don’t get it. Last night when I went to sleep I was King Shit in a blog world full of nerd turds. How did it all go so wrong? Perhaps I can find some constructive criticism within this avalanche of acrimony and use it to improve myself.

Well, at least I’m still slightly more impressive than the Food Babe. If I hope to maintain that status I better get ready to defend my position with some real evidence. I can’t just block people who challenge me and cower inside my echo chamber like some precious, little snowflake. That would be shameful.

Never to be outdone by the FoodBabe, Yvette would not only block someone who dared challenge her, she would also mobilize her Legion of Dopes to come after them. I suppose this is how factual disagreements are settled in the world of science today.

Replying to this influx of comments individually would be pointless. Since most of my critics appear to share the same brain, it would probably be easiest to address them all at once. Just bear with me here for a few minutes while I twink this all through. These comments are coming at me faster than a gay man in a uhhh…oh, wait.

Yikes. Tough crowd. I certainly didn’t set out to upset any gay men. The gay bath house was something I read about on Mark S. Hunt’s blog, My Fabulous Disease. I highly recommend checking out Mark’s work, unless of course you’re easily offended. Mark was awarded the National Lesbian and Gay Journalist Association’s “Excellence in Blogging” honor in 2014 and 2016, and was nominated for a 2015 and 2017 GLAAD Media Award. He never mentioned that “bath house” was the new “N” word for gay men. I also didn’t realize I wasn’t allowed to comically reference things that are openly advertised in major cities across the country. My apologies for such a vicious slam.

“Cover yourself, hate monger!” — Zindagi89
What happened there? Did your keyboard st-stutter?

I had no idea that mentioning the academic accomplishments of students in India would offend so many Caucasians. Perhaps they didn’t see this article in Quartz that details the current plight of graduates over there. Many students with high-level degrees in things like engineering and computer science are taking jobs as drivers, housekeepers, and mechanics to make ends meet. There simply aren’t enough jobs to go around in this intellectually gifted nation. India produces over 5 million graduates per year, and every single one of them is more qualified than the SciBabe in everything. I ran that line by my team of fact checkers and it stands.

I thought that a few jokes might get people to keep reading. It was a long rebuttal. I’m sorry if we don’t share the same sense of humor. I certainly didn’t mean to offend my gay, Asian fan base. If any of you are still reading, I want you to know how truly sorry I am. As a token of my apology, I sent a gift to your Supreme Leader. Judging by his response, I’d say we’re cool.

I never imagined that fans of an “edgy” blogger like the SciBabe could be so easily offended by my bullshit. Maybe if I tone it down a bit people might read beyond the first three paragraphs before “shame-raging” in the comments section. This reviewer thinks I should have taken the high road.

“Snark begets snark.” — Leviticus 16:12 or something

It’s not just the SciBabe who routinely uses sarcastic, condescending language when “career shaming” chiropractors. In the recently published LA Times article, Chiropractic has its Roots in a Ghost Story, author David Lazarus explains why he did not make a follow-up appointment with a chiropractor by saying:

“I didn’t bother mentioning that I’ve had the Casper the Friendly Ghost theme song playing in my head for days.”

In her review of the Medical War Against Chiropractors, Dr. Harriet Hall, MD writes:

“Chiropractors were forced to hide like Anne Frank or like slaves on the Underground Railroad. The Juice Man squeezed them for protection money; if they couldn’t pay, his thugs beat them up.”

Watch it, Harriet. SciBabe’s fans are a sensitive bunch and they might interpret that as minimizing things like the Holocaust and slavery.

Some of you may remember Clay Jones, M.D. as one of the chiropractic “experts” the SciBabe spoke with for her fair and balanced article. He’s a skeptical pediatrician who has authored at least a dozen articles on chiropractic for ScienceBasedMedicine. You can follow him on twitter @SkepticPedi, not to be confused with @SkepticPedo. That guy’s a different beast altogether.

“No way that chick is 14. I refuse to believe it.” -SkepticPedo

In Clay’s HILARIOUS, must-read, science-based spoof of the chiropractic profession, he writes:

“New evidence calls into question the belief that chiropractic subluxation requires a spine, much to the relief of millions of suffering invertebrate species.”

Considering I have ZERO background in science writing or blogging, I just assumed you had to be a bit of a dick in order to get your material read. I was following the precedent set by all those brilliant, medical minds who came before me.

But enough with all this nonsense. Let’s address the elephant in the room. Calm down, Zindagi89. It’s an expression, not a fat shaming joke.

By far, the biggest criticism I received is that I didn’t offer any evidence in support of chiropractic care.

I wasn’t really planning on being the sole burden bearer for demonstrating the effectiveness of chiropractic through data and research, but since I absolutely CRUSHED it with that chiropractic history lesson, I suppose I can give this one a go as well.

If I’m gonna dive into the research behind chiropractic I should probably start in the same place that the SciBabe and her wicked band of flying monkeys get all their information from. Lucky for me, those “chiro-shaming” shitheads over at ScienceBasedMedicine have dedicated an entire section of their fancy, peer reviewed website to chiropractic research. Let’s take a peek.

The first study they look at is titled Spinal manipulative therapy for chronic low-back pain, from the esteemed Cochrane Database of Systematic Reviews. The SBM website describes it as “acute” low back pain, but the study they link to definitely says “chronic” low back pain. Eh, who’s got time for details? Certainly not these dopes.

This meta-analysis looks at all studies available up until 2009 related to Spinal Manipulative Therapy (SMT), and its impact on chronic low back pain. Since all studies are not created equal, the folks over at Cochrane analyze each study and rate the quality of them. The goal is to summarize the findings of these studies and determine how effective the treatment is.

ScienceBasedMedicine summarizes the results by saying:

“This meta-analysis supports the most critical view: the authors concluded that ‘SMT is no more effective in participants with acute low-back pain’ than shams and placebos. They say there’s a need for “an economic evaluation,” but a treatment cannot be “cost effective” if it is not effective.”

Low back pain is our bread and butter. I was kinda banking on this one to move me on to Level 2. If we’re no more effective than “shams” and “placebos” what the hell am I doing with my life? I should probably just tuck my tail between my legs (no offense, trans fans), apologize to these folks for fucking with them, and see myself out the door.

On second thought, SciBabe kinda screwed me on that whole “chiropractic injures children” study. Maybe I should read the actual study and see what the authors have to say for themselves.

“The results of this review demonstrate that SMT appears to be as effective as other common therapies prescribed for chronic low-back pain, such as exercise therapy, standard medical care or physiotherapy. However, it is less clear how it compares to inert interventions or sham (placebo) treatment because there are only a few studies, typically with a high risk of bias, which investigated these factors. Approximately two-thirds of the studies had a high risk of bias, which means we cannot be completely confident with their results. Furthermore, no serious complications were observed with SMT.”

There’s a pretty big difference between “no better than placebo” and “placebo studies sucked so we can’t really use them.” There’s also a pretty big difference between “not effective” and “just as effective” as exercise, medical care, and physical therapy. The fact that chiropractic showed no serious complications and may be more cost effective than other treatments is also a pretty big deal, but we’ll get back to that later.

When a pharmaceutical company wants to test a new drug, they separate people into two groups. One group (Experimental) gets a pill containing the active ingredient being studied, and the other group (Control) gets a pill without the active ingredient. It’s a little tougher to pull that off when it comes to things like joint manipulation.

In a lot of these studies, the “sham” treatment or “placebo” was a practitioner laying their hands upon the patient without actually delivering any kind of adjustive thrust. People with an IQ higher than the average SciBabe reader can usually tell what group they’re in based on whether or not anyone actually manipulated them. That’s why this systematic review of lumbar and pelvic thrust manipulation placebo studies concluded that researchers needed to up their game and ensure the “inertness of their placebo a priori, as a minimum standard for quality.”

Control vs. Experimental group in a standard acupuncture clinical trial

No big deal. ScienceBasedMedicine has another study which only validates the conclusions nobody else got from the Cochrane study. This next one is entitled the “Effectiveness of manual therapies: the UK evidence report

Those research rats over at SBM summarize the study:

“This review of all manual therapies focusses (sp) mainly on spinal manipulative therapy and massage therapy for low back and neck pain, with underwhelming results: both are “effective” in some circumstances but certainly not impressively so, and generally no different from other therapies that help a little but haven’t exactly put a dent in the epidemic.”

The people who actually performed the study describe it a little bit differently:

“The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions.”

This study looked at all peer reviewed clinical trials pre-2009 and rated the levels of evidence according to this chart:

For you chiropractors who gave up on science in the seventh grade: GREEN = GOOD : YELLOW = BAD

They applied the evidence rankings to various conditions. The results looked like this:

The researchers concluded:

Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is also effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain.

Licensed Neurologist and Professor, Scott Haldeman, DC, MD, Ph.D. (that’s right, this guy plays for BOTH teams; no offense, bi-readers) had this to say in his analysis of the study:

“Numerous claims made by chiropractors over the years, based on their clinical observations, have not stood up to critical analysis and the results of studies often suggest that these observations are due to placebo or the natural course of the disorder rather than the actual treatment. This has been true of a vast number of medical treatments. A recent Special Issue of The Spine Journal on Evidence Informed Management of Chronic Low Back Pain listed over 200 treatments currently being offered patients with low back pain, most of which are offered by medical physicians. Of these, less than 10% have a reasonable body of support based on high-quality clinical trials. The greatest research support was for therapies commonly used by chiropractors including the manual therapies, education, and exercise.”

Holy shit! Less than 10% of low back pain treatments had a reasonable body of high-quality evidence behind them? Sounds like a lot of those medical physicians need a refresher course in Research 101.

Just this year, the Journal of the American Medical Association published another Systematic Review and Meta-Analysis of Spinal Manipulative Therapy (SMT) for acute low back pain. The conclusion reads:

“Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.”

Critics of this study point to the large heterogeneity, meaning the results of the individual studies varied pretty widely. This is a fairly common occurrence in meta-analyses that review more than a handful of individual studies.

The other criticism is that the “modest” improvements in pain and function were similar to those seen with the use of NSAID drugs. What they fail to mention is this report which estimates that NSAIDs may be responsible for 100,000 hospitalizations and 16,500 deaths from the GI complications they cause alone. That’s in addition to the significant cardiovascular risks associated with the use of these drugs.

GI Complications associated with NSAID drugs

This 2013 study on low back pain used a “sham” treatment that mimicked both the “acoustic and mechanical sensations” of an actual manipulation without using the proper positioning. It was published in the medical journal Spine. It concluded:

“This is the first time that spinal manipulation was investigated in a double-blinded randomized controlled design showing clear superiority compared with placebo and NSAID.”

“High velocity, low amplitude (HVLA) manipulation can be recommended for the therapy of acute nonspecific LBP.”

“Final evaluation showed manipulation being significantly better than NSAID and clinically superior to placebo.”

This 2011 study published in Spine even touts the benefits of maintenance chiropractic care. It concludes:

“Nonspecific LBP represents about 85% of LBP patients seen in primary care. About 10% will go on to develop chronic, disabling LBP.”

“This study confirms previous reports showing the SM is an effective modality in chronic nonspecific LBP especially for short term effects.”

…as patients did benefit from the maintenance treatments, we believe that periodic patient visits permit proper evaluation, detection, and early treatment of an emerging problem, thus preventing future episodes of LBP.”

For the record, that study was authored by two medical doctors and published in a medical journal. So put that shit in your pipe and smoke it, BOSS BILL!

Who’s the boss now, bitch?

This 2010 study funded by the US Dept. of Health and Human Resources looked at neck pain in the senior citizen demographic. It concluded that

“Spinal Manipulative Therapy with Home Exercise resulted in greater pain reduction after 12 weeks of treatment compared with both supervised exercise plus home exercise and home exercise alone. Supervised exercise sessions added little benefit to the Home exercise alone program.”

This 2013 study out of Switzerland for patients with cervical radiculopathy caused by a cervical disc herniation and confirmed on an MRI found that after one month of spinal manipulation 68.9% of patients were better and after 3 months 85.7% of patients were better. While not a blind, controlled study, it certainly shows promise for an effective treatment option that doesn’t involve injections or unnecessary surgery.

This meta-analysis looked at the medical literature from 1980 through 2006 and rated noninvasive interventions for neck pain. The authors concluded that therapies involving manual therapy (like manipulation) and exercise were the most beneficial of all noninvasive options. The combination of those two therapies is something chiropractors around the world have been doing for years.

BUT THE STROKES! WHAT ABOUT THE STROKES?

“Wow. No one has thought about us in years.” — The Strokes

Search the words “chiropractic” and “stroke” on ScienceBasedMedicine and your computer may overheat from all the results that come back. In this article, Harriet Hall M.D. writes about the dangers of chiropractic manipulations causing strokes by rattling off a few individual case studies from the medical literature. Funny enough, she opens this article by shitting on chiropractic research, saying it is of poor quality and made up of mostly case studies which hold no merit. I’m seeing a pattern here.

As with any health care treatment, there are some risks associated with chiropractic care. The most publicized of these risks is the idea that manipulation of the cervical spine can cause a dissection of the arteries which run through the neck and possibly lead to a stroke.

This 2007 national survey published in Spine investigated the safety of cervical manipulation. The survey found that in over 50,000 adjustments administered to 19,722 patients, there were absolutely ZERO serious adverse events reported.

This 2008 Cassidy study showed that the rate of vertebrobasilar stroke following a visit to a chiropractor was no different from that of visiting a family physician. They put the risk at 818 strokes per 100 million people. They theorize that people seeking treatment for neck pain, whether it be from a chiropractor or MD, were most likely already in the process of suffering a stroke. The reason that more young people experienced these strokes after visiting a chiropractor might just be due to the fact that more young people sought chiropractic care as their first treatment option.

This study seems to support that theory by saying that “chiropractic manipulation of the neck did not cause strains to the internal carotid artery in excess of those experienced during normal everyday movements.”

This most recent 2016 Systematic Review and Meta-analysis of chiropractic care and cervical artery dissection also concluded that “there is no convincing evidence to support a causal link between chiropractic manipulation and cervical artery dissection.”

That review was conducted by a team of M.D.’s in the Department of Neurosurgery at Penn State Hershey Medical Center. Whaddya think of that shit, BOSS BILL?

Ever notice how people who call themselves “Boss” on the internet are rarely the boss of anything in real life?

The best estimates available right now are 0.05–0.1 per 100,000 for serious complications after chiropractic manipulative therapy. To put that into perspective, this study published in the European Heart Journal estimates that consumption of any kind of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, could increase your risk of heart attack by 31%. Many medical physicians still use these drugs as their first treatment option for musculo-skeletal complaints

In 2010, Spine would publish their 2010 Outstanding Paper in Medical and Interventional Science selection, Chiropractic Hospital-based Interventions Research Outcomes Study.

The authors of this study wanted to see what happened when they treated people for acute mechanical low back pain according to the best evidence available. Since chiropractic treatment was backed by considerable evidence, this meant we were finally getting our call up to the Big Leagues!

The treatment groups looked like this:

Drum roll, please!

The authors would conclude:

“The evidence-based care group demonstrated significantly greater improvements in reported function through 6 months follow up.”

“The results of this study demonstrated that in equivalent groups of patients with Acute Low Back Pain of less than 4 weeks duration, carefully controlled and comprehensive clinical practice guideline based care was associated with greater improvement…”

“This study follows two previous studies conducted by our group that demonstrated that treatments commonly recommended by primary care physicians are often highly guideline discordant, and other studies have demonstrated that PCP’s are highly resistant to changing their patterns of practice for managing patients…”

Considering this Consumer Reports survey found that 50% of respondents who saw a primary care physician for low back pain were given a prescription for an opioid pain reliever, one has to wonder what could have been if people just followed the evidence based guidelines like chiropractors have been for years.

This study performed at Jordan Hospital in Massachusetts had similar findings. They decided to try a multidisciplinary approach to treating back pain based upon the latest evidence available. Results for the patients treated by doctors of chiropractic were an average of 5.2 visits at a cost of $302 per case. The average pain rating scores of patients went from 6.2 out of of 10 to 1.9 out of 10 with 95% of patients rating their care as “excellent.”

Chiropractors were able to get fantastic results and be the most cost effective option. Not bad for a bunch of magnetic healing witch doctors!

Chiropractor at Jordan Hospital doing how we do

This 2014 study from the Journal of Occupational and Environmental Medicine also concluded:

Care congruent with 10 of 11 guidelines was linked to lower total costs. Of the five patterns, complex medical management and chiropractic reported the highest and lowest rates, respectively, of guideline-incongruent use of imaging, surgeries, and medications, and the highest and lowest total costs.

This table from the study found that when they added up the direct cost (treatment/prescriptions) to the indirect cost (worker’s compensation/disability/absenteeism), the total cost associated with low back pain treated with medical management was almost 10x what the chiropractic care group cost.

Considering this report estimates that about $90 billion is spent on the diagnosis and management of low back and neck pain every year, with an additional $10 to $20 billion annually attributed to economic losses in productivity, how much longer can we afford to ignore what the evidence is telling us?

No offense, Asian smokers

Another promising study to come out in recent years is this 2013 study titled, “Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain.”

The patients in the Standard Medical Care control group were given access to a focused history and physical examination, diagnostic imaging as indicated, education about self-management, pharmacological management with the use of analgesics and anti-inflammatory agents, physical therapy, and referral to a pain clinic.

The experimental group was given access to all of those same treatments with the addition of two visits per week with a chiropractor for 4 weeks.

The results showed:

“There was a statistically and clinically significant benefit to those patients receiving chiropractic manipulative treatment…”

“73% of participants in the SMC plus CMT group rated their global improvement as pain completely gone, much better, or moderately better, compared with 17% in the SMC group.”

“Sup, ladies?” — The Gorsk

This study would fail to impress the chiropractic profession’s loudest online critic, Level 17 Dungeon Master and all around condescending douchebag, David Gorski, M.D.

The Gorsk is an oncologist who became obsessed with alternative medicine back in the 90’s. He is currently the Managing Editor at ScienceBasedMedicine. He used to run a blog called Respectful Insolence under the name, Orac. He adopted the name from British 70’s sci-fi TV show, Blake’s 7. According to the Wikipedia page for Blake’s 7, Orac is a highly advanced supercomputer developed by the scientist Ensor, and brought aboard the Liberator by Blake and the others at the end of Season One.

This nebbish dweeb deliberately misrepresents data and routinely omits research studies from his “Science Based” website when they don’t align with his anti-chiropractic views. He even has the balls to write shit like this on a regular basis.

Yyyyyeeah…….Orac. Chiropractors have delusions of grandeur.

The Gorsk just refuses to believe that patients can benefit when health care professionals are able to remove ego and dick size from the equation and follow the guidelines supported by the best evidence available. My guess is it’s because he only appears to have one of these things in abundance while SEVERELY lacking in the other.

In his analysis of the study, the Gorsk dismisses the results by saying, “Of course they did better. They got manipulation similar to physical therapy seven times during the eight weeks.” He then proposes what researchers should have done differently to compare various treatments. Nevermind that the whole fucking purpose of the study was to compare “what we usually do” to “what we should be doing based on the evidence.” Nevermind the fact that a third of the people in the control group were put on a regimen of actual physical therapy, including stretching, electrical stimulation, exercises, and heat. The only thing this geeky gobshite did get right was when he said, “Obviously, chiropractic is not physical therapy.” Obviously.

Chiropractors spend years learning how to deliver spinal manipulations safely and effectively, first in chiropractic school and then in the real world, using it as the cornerstone of their treatment every day. According to this website, physical therapists learn spinal manipulation in a 2-day weekend seminar.

The last thing I want to do here is start a pissing war with physical therapists. One of my best friends is a physical therapist who practices right up the road from me. When I have a patient who needs post-surgical rehabilitation or a focused regimen of active rehabilitation exercise, I send them his way. I know a bit about rehab exercise, but he knows a lot more. Besides, I can’t really fit all that fancy exercise equipment in my mall kiosk anyway. In return, when he has patients he feels can benefit from joint manipulation, he sends them to me. He knows some joint adjusting techniques, but he realizes I know a good bit more because it’s what I do every single day.

You know who benefits most from this arrangement? Our patients who get better. Imagine that? A world where health care professionals work together for the greater good of the patient. If that happened more often maybe we would see a lot more “anecdotal” evidence lining up with what the “actual” evidence has been saying for years.