Chiropractic & Osteopathy

It was announced this week that Chiropractic & Osteopathy will be in CINAHL Cumulative Index to Nursing and Allied Health Literature, is the most comprehensive resource for nursing and allied health literature.

C&O is an open access, peer-reviewed online journal that aims to provide chiropractors, osteopaths and related health professionals with clinically relevant, evidence-based information.
I serve as an Associate Editor for C&O
SMP

Killer Peanuts?

No this isn't about the tainting of peanuts with Salmonella, this is about peanut allergies. A couple of years ago I was waiting for a flight out of Washington and struck up a conversation with a man sharing a table with me. He was a dentist now working full time at NIH. He told me he was working on a project that was attempting to stem the tide of the epidemic of peanut allergies.

My two children do not have the allergy but we've been affected by it because of children with the allergy in their schools. There are no peanut classrooms, no peanut lunch tables etc. I used to like getting peanuts on air flights but not any more. In fact I have no recollection of any talk about peanut allergies during any of my years in public school (ending in 1975). The epidemic of peanut allergies is relatively new and has changed much in America. But where did it come from?

This NIH researcher told me that in Israel peanut allergies are almost non-existent. The theory is that because one of the first solid foods Israelis give their children contains peanuts. It is called Bamba and is sort of like a Cheese Doodle or Cheetos with peanut flavor instead of cheese. While so many Americans feed their infants Cheerios as one of their first foods for Israelis it is Bamba. In the US for a long time parents have been admonished to keep their infants away from peanuts.

He told me that NIH was now funding a study to see if children feed peanuts early in life are less likely to get the allergy. The NY Times recently reported that early results suggest that early exposure to peanuts reduces the risk of peanut allergies.

The study, By Du Toit et al. was published in November of 2008 and compared the risk of peanut allergy amongst Jewish children in the UK to those in Israel. By using only Jews the researchers eliminated the possibility any differences were due to differences in ethnicity. They found a 10 fold increase in the likelihood of having peanut allergy amongst the children from the UK.

I guess my mom didn't harm me by giving me peanut butter when I was an infant. Maybe we need to bring back Mr. Peanut

SMP

Plateletes

The NYTimes recently published an article on platelets as a soft tissue treatment. ABC News also did a piece on this use of platelets to treat soft tissue problems. Back in 1993, I was at an orthopedic grand rounds at Yale where the speaker was Albert Banes, PhD. Dr. Banes has done pioneering research on what stimulates fibroblasts to multiply and synthesize collagen (collagen is needed to repair soft tissue injuries). His work has shown that intermittent loading (application of force) stimulates both replication and synthesis in fibroblasts. He also talked about how platelet bound growth factor also does this.

Dr. Banes related an anecdote that is similar to these stories. He talked about how an orthopedist at UNC, where Banes worked had chronic patellar tendinosis that was refractory to treatment. The doctor, a triathlete had suffered with the pain for over a year. Banes suggested based upon research they were going to do that the orthopedist get his own blood spun down and inject his tendon with his own platelets. This eliminated the symptoms in less than a week.

I've been teaching, for a few years, a treatment, Graston Technique that research also shows stimulates fibroblasts to replicate and synthesize collagen.

SMP

Court Ruling on Vaccine and Autism Link

A federal vaccine compensation court recently ruled that the MMR (measles, mumps rubella) vaccine does not cause autism. This case is very important because of the standard the court used to make its decision. As opposed to criminal cases where the standard is "beyond a reasonable doubt" this special court used "preponderance of evidence" as the standard. The judge, called a "special master", George L. Hastings, Jr ruled that the evidence was overwhelmingly contrary" to the argument made by the parents seeking compensation in this case. In fact he said that the family had been "misled by physicians who are guilty, in my view, of gross medical misjudgment."

The point is that those who have been telling parents of autistic children that the cause is vaccines are really the problem here. In fact, I think they are no different than those who claim the holocaust didn't happen or the flat earth society members who claim NASA never went to the moon. They create a controversy where none actually exists. Unfortunately, the media at times accepts deviant viewpoints as the "other side of the coin" and gives them the opportunity to present rebuttal, when they have no more valid a point than holocaust deniers or flat earthers do.

I know that a lot of my colleagues have a different opinion. Many chiropractors are as opposed to vaccination as religious zealots are to evolution. They cite specious research and ignore valid studies that refute their point. I understand why they have this position, even if I reject it out of hand. They tend to have anti vaccination positions for what they believe are good reasons.
Their experience is that the AMA ignored evidence that chiropractic care can be quite helpful when they engaged in an illegal boycott of the chiropractic profession (see Wilk v AMA). Thus, many in the chiropractic profession recall this history and do not trust medical research, especially when it contradicts their one of our basic philosophies, that nature is the best medicine. Then of course there is all that anecdotal evidence which just reinforces the distrust of medical interventions.

Saying I understand where the anti-vaccination beliefs come from doesn't mean I agree with them. In my ethics column in Dynamic Chiropractic, I've written about the ethics of being opposed to vaccinations. This ethics column resulted in the most hate mail (hate e-mail) I've ever received from my peers. One, a former student suggested I help my profession by killing myself. This type of argumentum ad hominem is common when one attacks ideas in my profession. Unfortunately, despite the talk of chiropractic philosophy (philosophy is the love of learning), free thinking often isn't loved too much. BTW there is better evidence now that suggests that cervical manipulation does not cause stroke.

SMP

Need x-rays (or CT or MRI)?

Many healthcare providers operate under the aphorism "to see is to know" and order spinal x-rays or MRI immediately upon seeing a patient with low back pain. This week the venerable British medical journal The Lancet published a systematic review and meta-analysis concerning imaging and low back pain.

Systematic Reviews and Meta-analyses
A systematic review is a type of paper wherein the authors search the biomedical literature (research) for every paper on a topic. They use a plan that details how they will search and what factors about a study should cause it to be used or not used in their review. Then they use a detailed method to determine the quality of the study. Not all research is done equally well so the studies must be critically appraised, tossing out those studies that have fatal flaws in their design. This is a systematic review. The remaining studies are then subjected to a meta-analysis. A meta-analysis is done by collecting data from the remaining high quality studies and essentially pooling them statistically into a single larger more robust study. As poker has a hierarchy of more important hands (e.g. 3 of a kind beating a pair) with scientific research there is a hierarchy and systematic review and meta-analysis are the research equivalent of a royal flush in poker.

From the study's abstract:

Interpretation Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.

By lumbar imaging the authors of this study mean x-ray, CT & MRI. Does not improve clinical outcomes means that getting the imaging studies does not help the patient get any better. Thus, they found from the research that has been published is that patients with acute or subacute low back pain who did not have indications of serious underlying condition there was no difference in the way the patient's felt whether they had imaging or not. Simple thought, if doing the imaging study, which takes both time and money and if radiographs or CTs exposes one to radiation, but does not result in a benefit why do them?

What are the "indications of serious underlying conditions"?

• History of cancer
• Rapidly progressive or severe neurologic deficits - loss of muscle strength, fecal incontinence, and bladder dysfunction (incontinence or retention)
• Potential infection - fever, intravenous drug use, or recent infection
• Vertebral compression fracture - older age, history of osteoporosis, and steroid use
• Ankylosing spondylitis - younger age, morning stiffness, improvement with exercise, alternating buttock pain, and awakening due to back pain during the second part of the night only
• Some organic diseases - pancreatitis, nephrolithiasis, aortic aneurysm, endocarditis or viral syndromes,

There are those who might say that these guidelines do not apply to chiropractors because we look for other important things on radiographs. Well about a year ago a group of chiropractic radiologists came up with essentially the same spinal diagnostic imaging guidelines. Why did the chiropractic researcher find the same thing as medical researchers? Because modern chiropractors and modern medical doctors use imaging for the exact same purpose - to ensure that the patient does not have a serious underlying disorder which isn't likely to respond to non-surgical management. For the vast majority of people with acute/subacute low back pain non-surgical management is best, imaging doesn't improve the patient's outcome (one doesn't get better faster or improve more) and doctors of chiropractic are the non-surgical spinal specialist. See the latest evidence on low back pain spinal manipulation from the World Health Organization's task force for the Bone and Joint Decade.
So if your doctor (MD or DC) is rushing to do diagnostic imaging when you have acute low back pain. Maybe, just maybe you need to find a doctor who is practicing with 21st century knowledge. How to find such a doctor? One source is the NCQA Back Pain Recognition Program. One might also look at the member ship of The West Hartford Group, Inc

SMP

Fibromyalgia

I just saw an advertisement in my local newspaper for a seminar a chiropractor was running on chiropractic treatment of fibromyalgia syndrome (FMS).
This is an issue that is dear to my heart because not only do I lecture on fibromyalgia but I have also published on this.

Schneider MJ, Brady DM, Perle SM. Commentary: differential diagnosis of fibromyalgia syndrome: proposal of a model and algorithm for patients presenting with the primary symptom of chronic widespread pain. J Manipulative PhysiolTher. 2006 Jul-Aug;29(6):493-501.

Our paper is available for free, click on the link above.
In our paper we basically deal with the fact that there are three classes of conditions that are commonly misdiagnosed as FMS.

• Medical Conditions - a competent diagnostic work up must be done to rule out some other cause for the patients widespread pain for example: Hypothyroidism, anemia, rheumatoid arthritis, Lyme disease, rheumatic auto-immune disorders such as ankylosing spondylitis or scleroderma, multiple sclerosis, and occult malignancy
• Functional Metabolic Disorders - these are subclinical disease states and disorders involving dysfunction of internal organs and metabolism, rather than true pathology
• Musculoskeletal Disorders - various conditions while documented in the literature are not known universally, for example joint dysfunction (a name for the joint that causes symptoms which resolves after manipulation), myofascial trigger points or sclerotomal pain. Murphy et al present a good diagnosis-based clinical decision rule dealing with how to diagnose these conditions.

Now one might say that the last category should be within the competency domain of all chiropractors. For various reasons (e.g. where they went to school or their anachronistic beliefs about chiropractic) some are ignorant of all the potential conditions that may look like FMS but really only are these muscuolskeletal dysfunctions.
Now the point of this blog. There is compelling evidence at this time that FMS is not a condition of the musculoskeletal system. Clearly it is pain in the musculoskeletal system but that does not mean that there is anything wrong with the musculoskeletal system just that is how our brain interprets the symptoms.
For a good review of the pathophysiology of fibromyalgia see:

Abeles AM, Pillinger MH, Solitar BM, Abeles M. Narrative review: the pathophysiology of fibromyalgia. Ann Intern Med. 2007 May 15;146(10):726-34.

Abeles et al review on fibromyalgia is available free just click on the link above.
The basic problem with FMS is a change in how the brain perceives touch and interprets it as pain. Thus, treatments geared towards affecting any changes to the periphery (e.g., muscles, joints, ligaments) are not likely to benefit the patient with FMS. Aerobic exercise (which involves using these peripheral tissues) is beneficial because of its mood elevating effects.

The patient with "FMS" who finds that manipulation, massage, vitamins & other supplements is an effective treatment more than likely had successful treatment of some other condition that was misdiagnosed at FMS. I guess for that person they are lucky that the stumbled upon someone who mis-treated their misdiagnosed FMS. The real problem is the vast number of people with real FMS who stumble along between health care providers who haven't correctly diagnosed FMS or who have but offer inherently ineffective treatments.

SMP

A healthy skepticism - scoliosis

A few years ago there was a lot of buzz about a "new" treatment for scoliosis. It was the Copes Brace. I saw a bunch of advertisements for this in chiropractic trade papers. I heard people talk about it glowingly at non-scientific meetings. A say "non-scientific meetings" becuase I never saw a single study or presentation at a peer-reviewed conferece. It all seemed like hype to me and as if the brace was nothing more than a new packaging of a Boston brace with a specific bit of marketing towards chiropractors. Well interestingly the "developer" just got jail time in Lousiana for insurance fraud becuase he was practicing without a license. The developer of this method did not hold any health care licenses. See:

http://www.2theadvocate.com/news/38738672.html

When my former students asked me about this method I always suggested a healthy dose of skepticism. I've found that often the bigger the hype the smaller the validity.

SMP