NPR's Fresh Air did an interview yesterday with Dr. Gawande. This is adds to the discussion from his article that I talked about in my earlier blog on this. He talks about some interesting comments made to him by doctors from McAllan. It's worth listening to in addition to reading the article in New Yorker. Instead of being sick to death many Americans are sick to debt. They are in so much debt that they have declared bankruptcy. To me this is obscene that people, in some cases, though no fault of their own have become sick to debt or so ill that their physical illness leads to the ultimate financial illness - bankruptcy. A study in the American Journal of Medicine found that in 2007 62.1% of Americans who filed for bankruptcy did so because of medical bills, over $5000. I think that the Obama administration is correct that health care costs need to be reduced if we are going to improve our economy. We don't have the best health care in the world but we certainly have the most expensive.
- Spinal cancer
- Cauda equina syndrome
- Infection
- Ankylosing spondylitis or another inflammatory disorder
- Fracture
An ultracrepidarian is a person who professes expertise the they do not posses. This is an epithet not often used but I am fond of and have used in presentations and my ethics column. Some might say that fondness is because it should be applied to me. Nevertheless, I like it because I find so many experts who pontificate on that which they know so little. Think of my earlier blog entry about Katz. The NYTimes reports on the battle against the use of the best evidence in health care. Once again it is reported that one of the biggest problems in getting good health care is the resistance of health care providers to changing the voodoo that they do to treatment that actually works.The desire to be right and the desire to have been right are two desires, and the sooner we separate them the better off we are. The desire to be right is the thirst for truth. On all accounts, both practical and theoretical, there is nothing but good to be said for it. The desire to have been right, on the other hand, is the pride that goeth before a fall. It stands in the way of our seeing we were wrong, and thus blocks the progress of our knowledge.The Times article suggests that most doctors are more interested in having been right, rather than being right.
My last blog entry Swine Flu & Chiropractic is stirring up a hornets nest. Of course you wouldn't know that by looking at my blog because no one has posted any comments, so far. I have received quite a few emails. All of the emails sent to me directly by the person commenting have been complimentary.There is a growing body of good scientific evidence that spinal manipulation can be an effective treatment method for neck pain, headaches and low back pain.Tell me where does it say that we should "stick to headaches, low back and neck pain"? It doesn't. It says that there is a growing body of good scientific evidence on three conditions. That's all. I didn't mention any others.
"Absence of evidence is not evidence of absence"This one is often cited by members of my profession about those things we have no evidence for. For example using chiropractic care to prevent or treat swine flu. While this is true I think what is also important is another quote from Sagan:
- "The Dragons of Eden"
"I believe that the extraordinary should certainly be pursued. But extraordinary claims require extraordinary evidence"The claim that spinal manipulation will improve immune function to the extent that it can be used to prevent or help treat the flu is clearly an extraordinary claim. I absolutely believe that it should be researched, just it is not my area of research interest. Some might say why not no harm. Well that is true as long as the public isn't lead to believe that this is a validated treatment. Until the evidence is found, we, the chiropractic profession, have to stop making the claim that chiropractic care will help prevent or treat the flu, which is what the blogger I was responding to wrote. He said that one of the "Sure-fire Strategies to help you and your family respond to the threat of the flu" is chiropractic.
- " Broca's Brain"
I recently saw a blog that suggests that the second best of the "Sure-fire Strategies to help you and your family respond to the threat of the flu." is chiropractic. Now don't get me wrong, I'd love to be able to say with a straight face and the research to back it up that going to see a chiropractor would help you prevent or even get better from the swine flu, er I mean Influenza A(H1N1) (surely we don't want to insult swines). But honestly I think it is intellectually dishonest and a public disservice to imply that a chiropractor has unique therapeutic tools that will help prevent or treat the flu.If there is a fundamental question in biomedical research it is does a treatment "work". By "working" most people mean is the treatment clinically effective. The first time this question was asked in a rigorous scientific way is often cited as the work of the British Naval physician James Lind, MD (1716 - 1794). Lind, a Scotsman, one might say is personally responsible for the British being nicknamed, Limeys. His research showed that citrus juice "worked" as a treatment for scurvy, which of course we now know is due to a Vitamin C deficiency that the citrus provide a good supply of. I just read a blog that critiqued a paper by Redwood and Globe. This blogger seems to live in a different chiropractic planet than I do. He believes that chiropractors should be allowed to turn patients into annuities for doctors, that is put them on extended care plans which have not been shown to be beneficial to the health of the patient. The NYTimes now reports on a treatment for peanut allergies using...peanuts. This information comes from two abstracts reported at this weekend's American Academy of Allergy, Asthma & Immunology annual meeting (see abstracts #576 & 665 - free PDF). In case someone thinks this is weird that I've blogged twice on peanut allergy - my interest in this was created by the serendipitous meeting with an NIH researcher. I have discovered a real stroke of genius. If one says often enough and has enough money to put billboards up that a chiropractor caused a stroke, then it must be true. Madison Ave. discovered this years ago. When I started chiropractic college chiropractors were, according to the AMA, an "unscientific cult". Heck, some essentially still say that (see my Blog entry on Katz and Dogma). Nevertheless, Sharon Begley's column in Newsweek points out that standard medical practice is often unscientific. Looks like the pot calling the kettle black. 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.
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.
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.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."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-analysesFrom the study's abstract:
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.
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?
I just saw an advertisement in my local newspaper for a seminar a chiropractor was running on chiropractic treatment of fibromyalgia syndrome (FMS).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.
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.
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: I was talking to a friend today and she brought to mind an exchange between Murray Katz, MD and me from the McGill University, Faculty of Medicine, Continuing Medical Education discussion board. I thought that I would post some of it here.Re: High Neck manipulation Posted by Murray on Jul 23, 2008 9:38
The comment on various studies by Mr. Perle (with all due respect none of his many degree were obtained under the direction of a Faculty of Medicine) are typical of the chiropractic “spin”. There are endless studies on homeopathy but there is more urine from a shark swimming on Mars than the ingredients on the bottle. Likewise, this is no such thing as chiropractic vertebral subluxations. The study he quotes using billing numbers is typical of chiropractic studies which Wallace Sampson and J. William Kinsinger wrote about in their paper “Producing Quack Studies for Quackery”. To show the extent of this quackery, a German study using actual hospital records and also going backwards found 36 cases of chiropractic stroke. Chiropractors want us to waste our time discussing their studies. There are a few chiropractors who have crossed over to science. These admit freely there is no such thing as subluxations. They no longer claim to have meaningless degrees. They start with the basic question, why are 200 million high neck manipulations a year being done on everyone from newborn babies to senior citizens. What is the diagnosis? The following commentary was published last week in the Calgary Herald in Alberta. It deals directly with the issues. Re: "Anecdotes are not enough to condemn chiropractors," Susan Martinuk, Opinion, July 18. Susan Martinuk's column is typical of chiropractic spin. Seventy years of scientific literature from all over the world, the warnings of neurologists all across Canada, three coroners' reports involving the deaths of three young women in Canada as well as an endless number of life-devastating strokes are not anecdotes! Almost without exception, all of these victims of chiropractic neck manipulation stroke and death have a number of things in common. They did not have pain in the highest neck area. They had their highest neck manipulated with the diagnosis of vertebral subluxations, something which does not exist. No one should die or live a disabled life for a condition that does not exist. Highest neck manipulation was done on them at almost every visit no matter what the complaint, sometimes 50 or 100 times, or more. Does it ever work? From newborn babies to senior citizens, Albertans are being told they have vertebral subluxations and need to have the highest neck manipulated. This is a scam and a fraud paid for out of the public purse and your own pockets. Victims and physicians are asking for six reasonable and scientific restrictions to be placed on all chiropractic highest neck manipulation. None of these will prevent the use of scientific manual therapy for neck pain, most of which is done responsibly by physical therapists. These restrictions are that highest neck manipulation should not be done on babies and children, not for claims that this can provide "wellness" to the body, not 50 times on the same person, not to claim to treat liver, heart or other organ diseases and most important, not for the claim that there are vertebral subluxations in the highest neck area. Physical therapists abide by these restrictions and hence have no strokes or death due to neck manipulation. The Minister of Health of Alberta has already been warned to enforce these restrictions and since Sandra Nette's stroke, we now have another case in Alberta of a young man who suffered a locked-in stroke and has come partly out of it. There are others. The reason the College of Chiropractors of Alberta, there to supposedly protect the public, will object to these sensible restrictions is that their officials all believe in this quackery. In my own experience, I was placed on a table from which a part suddenly dropped away and as a result, I had a stroke. The College of Chiropractors fully supports such quack machines claiming they can treat neck pain? Never allow a chiropractor to place you on a drop table machine. In the words of the Wellness Center in California, never agree to neck manipulation. Diana Dingley, Chestermere, (a stroke victim), and J. William Kinsinger, MD, Edmond, Okla. © The Calgary Herald 2008
Re: Re: High Neck manipulation Posted by Stephen on Aug 02, 2008If anyone is interested in the whole exchange please go to McGill's web site
7:08
Dear Dr. Katz,
It appears to me that somehow having a medical degree has conferred upon you a level of arrogance that most other professionals do not possess. Who gave you the right to determine who has or does not have a valid doctorate? I think that government has that prerogative and it has spoken in Canada, despite your views. By your thinking, I ought refer to you as Mr. Katz because, with all due respect, none of your degrees were obtained under the direction of a Faculty of Chiropractic. This rather juvenile of you don’t you think?
You write that “few chiropractors who have crossed over to science”. I searched pubmed and cannot find a single paper in the peer reviewed literature that you have authored only one letter to the editor. This sounds as if the pot is calling the kettle black. Your degree and likewise your comments do not provide me with evidence that you have “crossed over to science”. Coming from a scientific profession does not mean one is scientific. One actions and words speak louder than ones degree.
On the other hand my publishing record in the peer reviewed and pubmed indexed literature is available.
http://tinyurl.com/6y34tf
Likewise one can find my writings on ethics within chiropractic.
http://www1bpt.bridgeport.edu/~perle/ethics.htm
http://www.acatoday.org/level2_css.cfm?T1ID=15&T2ID=160
And finally I am quite clear when it comes to subluxations.
http://www.chiroandosteo.com/content/13/1/17
I suggest you read what I have published and stop assuming I defend bad chiropractic practice, any more than I should accuse you of defending bad medical practice.
Of interest is the fact that the Cassidy (1) study I cited is published in the preeminent orthopedic journal. I can’t find Sampson and Kinsinger’s paper in pubmed. I guess it wasn’t published in quite as prestigious journal. One wonders what the scientific world has come to when such an important work is relegated to the scientific backwater and the quack studies of quackery that use billing records written by people with meaningless degrees is published in such a prestigious journal. Or maybe Dr. Katz’s view of the world is a bit askew.
Cassidy’s (1) study is a population based study rather than a retrospective review of hospital records of some hospitals, which the German study (which Dr. Katz alludes to but does not cite (2) is). It turns out that in the German study 50% of the so-called “chirotherapy” was provided by orthopedic surgeons and only 11% was provided by chiropractors. (2-3) I would suggest Dr. Katz, when using a study to cite the hazards of chiropractic care one should carefully read the study to ensure that the so-called chiropractic treatment was actually provided by chiropractors and not medical doctors.
One could debate the merits of each study but that does not appear to be what Dr. Katz would like to do. His modus operandi appears to be ad hominem attacks, the use of spurious literature, misquoting his own sources and “scientific” debate via newspaper. This is not an exercise I choose to engage in any longer. If the level of debate rises to a professional level, I shall respond appropriately.
Stephen M. Perle, D.C., M.S.
[1] Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver FL, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008 Feb 15;33(4 Suppl):S176-83.
[2] Reuter U, Hamling M, Kavuk I, Einhaupl KM, Schielke E. Vertebral artery dissections after chiropractic neck manipulation in Germany over three years. J Neurol. 2006 Jun;253(6):724-30.
[3] Wenban AB. Inappropriate use of the title 'chiropractor' and term 'chiropractic manipulation' in the peer-reviewed biomedical literature. Chiropr Osteopat. 2006;14:16.
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