Anonymous Criticism - Defending Ernst

Image via WikipediaAs with most bloggers who allow it I have received a variety of comments on my last blog, The self-importance of being Ernst.  Generally it is my policy not to allow anonymous comments.  Since I have the courage to identify myself in the blog I think anyone wanting to comment should do the same.  Maybe that's my self-importance or it is my belief that one should have the courage of ones convictions. 

Someone submitted a few comments in defense of Ernst to my blog and given that the email address is their web site and that their web site, which is just a tirade about various CAM methods, does not allow any commentary moderated or not from their readers I choose not to provide him/her with the links, i.e. advertising.  However, I won't hide behind my ability to block a comment and will paste each of the comments and I'll reply.  If my anonymous critic comes out from behind the curtain I might then publish as-is the words of this Wizard of Oz :)

Criticism 1

I noted in my previous blog posting that it was...unusual for Ernst to have a copy of Long's pre-submitted testimony, which was rejected by the CT Board of Chiropractic Examiners.  My anonymous critic says:

If you read the ‘Methods’ section of Professor Ernst’s original paper he said that “several experts were also contacted for further data”. Perhaps that is how he managed to see Preston Long’s document.

Well that would be reasonable except that, Long doesn't fit any one's definition as an expert.Secondly one needs to keep in mind that Ernst was conducting a "systematic review".  In a systematic review it is not uncommon to seek from other researcher, AKA experts their bibliographies of appropriate literature.  Clearly Long isn't a researcher on the topic (or any other that I can tell).  And one must remember that the data that Ernst was contacting others for was more papers in the scientific literature.  See a larger quote from the Methods:

In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data.

Criticism 2

Stephen Perle wrote: “What is the common feature of Ernst's citation of these deaths whose information or rather misinformation was obtained from a web site and the deaths reported by Long? Neither of these data sources were from the scientific literature. In his reply to our letter Ernst says "These cases were, however, merely added for completeness and not included in my total number of 26 cases reported in my review." Completeness? So adding people who didn't die after chiropractic spinal manipulation and weren't in the scientific literature adds completeness to a review of the scientific literature?”

Note that Professor Ernst said in his Introduction that:

Quote
“A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature.”

Note that he didn’t say he would *exclusively* look at the medical literature. Indeed, in the Methods section he was more specific, informing us that

Quote
“Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009)… *In addition*, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor.”

He goes on to say that many other fatalities seemed to have remained unpublished and gives examples of the testimony of Preston Long DC (whom it is likely that he contacted personally) which listed the family names of nine victims. Dr Long also stated that ‘many others are unknown hidden behind legal agreements of silence’. Professor Ernst then cites ‘names’ of further North American fatalities from the website www dot whatstheharm dot com

Well this isn't exactly true.  The purpose says: "In this review, I aimed to provide the basis for such a discussion by summarizing all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature." Well the problem is my anonymous critic is grasping at straws.  The purpose of looking in the departmental files or contacting experts are to find other papers in the medical literature that the search failed to find.

IF Ernst had a purpose that included all possible sources of information then that would have been in his methods.  As I noted earlier if Ernst had put the information from Long in his discussion to coincide with the assertion that many cases are remain unpublished I would have only commented on the apparent collusion with critics of chiropractic not the propriety of including Long's "testimony".

My anonymous critic goes on to note the Ernst cites the names of other American fatalities found on the web site (cited above).  Except that 5 of the 9 deaths that Ernst attributes to chiropractic spinal manipulation (in that paragraph of his paper but not in the total death count) did not die as a result of chiropractic spinal manipulation.  So again if Ernst had only talked about these deaths to buttress his argument that the literature lacks a presentation of all deaths after chiropractic spinal manipulation I would not have criticized his lack of following his own purpose.  But then again would have criticized his zeal to attribute all the deaths found on the web site to chiropractic spinal manipulation. 

Criticism 3

Stephen Perle wrote: “Wenban has detailed the commonality of wrongly ascribing adverse events of manipulation to the care of doctor’s of chiropractic.”

As Professor Ernst says in his response to Whedon et al, his original review contests that with good references. He also says he can not reasonably be expected to know of the ‘personal correspondence’ that Wenban and Bennett cited and asserts that the small discrepancies in numbers (about which they argue) are almost irrelevant.

You know if we were talking about hundreds or thousands or even hundreds of thousands of deaths one or two discrepancies wouldn't matter would they?  But and this is the amazing fact we are talking about a very small number - 26.  So adding one that doesn't belong is big.  I mean with a total of 26 in 115 years we are talking a 3.8% error.  OK the number is a small point - it just goes to the sloppy nature of the review.  Add a couple take away a couple and pretty soon you got nothing of substance in Ernst's "systematic review".
Criticism 4

Stephen Perle wrote: “Ernst says Cassidy's study has been repeatedly criticized for being flawed. The key word is repeatedly. This obviously repeatedly means more than once, which means that there must be more than one reference cited for that criticism. In fact, I think most would agree that repeatedly probably means many more than one. Well there is only one reference cited and what is that: Ernst E. Vascular accidents after chiropractic spinal manipulation: myth or reality? Perfusion 2010; 23: 73–4. No it can't be the only criticism in the scientific literature (not the blogosphere mind you - this is science we are talking about here) that Ernst can find is his own (now you get the idea about the title for the blog).”

Professor Ernst did not qualify where the study had been repeatedly criticised. Further, it you’re going to discount the blogosphere, then your blog post here should not, in any way, be taken seriously by the scientific community.

Well actually Ernst did qualify where the study had been repeatedly criticized.  He provided ONE reference to the journal he is the editor-in-chief of.  Since I know that my anonymous critic isn't a scientist (I know this from their former blog name) I'll forgive his/her ignorance about citation (and purpose above).  However, given the fact that Ernst had no problem citing a web site as a source for the purported deaths, I am sure if his source for "repeated criticism" of Cassidy was the blogoshere or other web sites (even my anonymous critic's) there's no reason to suppose he wouldn't cite them.  The fact of the matter remains that there have been no substantive criticism of Cassidy's methods in the scientific literature.  There has been only one letter to the editor by Maigne. It is my opinion that Cassidy et al adequately responded to Maigne but clearly there isn't "repeated criticism" nor criticism substantive enough to deal a death blow to the validity or importance of Cassidy's findings. 

I think one of the most important points one needs to keep in mind regarding cervical manipulation and stroke is that the only people going ape about this issue are critics of chiropractic.  It just isn't an issue to epidemiologists nor any of the stroke associations.  For example I was at a conference this year in Connecticut put on by the Connecticut Department of Public Health and the American Stroke Association on stroke in the young adult.  Not one speaker mentioned cervical manipulation the whole day.  The critical problem when it comes to stroke in the young adult is that despite its prevalence many health care providers don't recognize the condition because they think stroke is a condition of older people.  Here are the stats I heard for strokes in CT for 2009, keep in mind the population of CT is about 3.5 million

                Age          Number of deaths

45-65             2047

25-44               354

15-24                 34

4-14                   10

<4                        8

Clearly stroke is a horrible event to occur to anyone young or old.  I know first hand from family members how devastating it is but right now the evidence just does not support a causal relation between cervical manipulation and stroke.

Finally I agree completely with my anonymous critic that no one in the scientific community should take my blog or any other blog seriously from a scientific stand point.  That is why I didn't post anything on this blog until my letter to the editor was published.  As I noted in the previous posting the way science progresses is not only the publishing of ones results but that there is an opportunity for critique in the same venue via letters to the editor.  The more scientifically minded should read Ernst's paper, the letters to the editor and his response.  In fact it is this reason that I have not posted my anonymous critics comments as is.  Because I don't want to encourage people to see this person's opinion without the opportunity for rebuttal.  If they posted their name and not their URL I would have not written a whole blog post and just let the comments go and commented on them as I have done herein.

Criticism 5

Stephen Perle wrote: “Now to his critique. I won't reproduce it here…”

Why not? For anyone wishing to read it, there’s a link to the full text of it in the chiropractic section of my website. It really is quite revealing.

Well the simple answer is I don't violate copyrights.  The paper is copyrighted and neither my anonymous critic nor the other web site where I found the paper have anything about permission granted  from the copyright holder to publish the paper on the web.  The journal nor Ernst on his web site have a PDF available for free.  I guess if one is really agitated about the chiropractic profession it is acceptable practice to violate copyrights.  Zealotry trumps legality.

Also. I suggested that it is far better for people to listen to the cross-examination of Dr. Cassidy at the hearing that Long never came to.  Again here is a link to the CT-N video of Cassidy's half day on the witness stand.  Every point Ernst made and then some were tried by the two attorneys who cross-examined Cassidy.  Hear the answers from the horses mouth. 

Criticism 6

I think readers should be told that Dohos and Tragiannidis, of the Aristotle University of Thessaloniki’s Medical School in Greece, wrote to the International Journal of Clinical Practice in support of Ernst’s paper:

Quote:
“…we agree with Professor Ernst on the following points

• Vascular accidents after upper spinal manipulation can cause severe vertebral artery dissections;
• Numerous deaths have been associated with chiropractic neck manipulations;
• Many other cases are unknown behind legal agreements of silence
• Therefore the risks of chiropractic neck manipulations by far outweigh their benefits.”

Ref: Critique of review of deaths after chiropractic, 3. Dokos C, Tragiannidis A.
Int J Clin Pract. 2011 Jan;65(1):103-4.

The problem with  Dohos and Tragiannidis is that they provide no substantive evidence for any of their bulleted opinions above.   

Criticism 7 

I also think readers should be made aware of the following in the US:

Quote
"The National Quality Forum lists 28 ‘never events’ healthcare mistakes that should never happen and need to be reported. Death or serious disability from spinal manipulation is listed as no.16. But chiropractors do not have to report this because they have a loophole. The National Quality Forum demands it of clinics and hospitals but no reporting is mandated for individual doctor's offices where 99% of spinal manipulation is done. Chiropractors generally do not practise in hospitals or clinics."
Ref: Britt Harwe, open letter to the Editor, Focus on Alternative and Complementary Therapies, Volume 15, Issue 1, pages 87-88, March 2010.

OK and the point?  There are a lot of events that occur in private practices for which no reporting is mandated. 

In conclusion I am waiting for the wizard of oz to step out from behind the curtain or not. 

SMP

The self-importance of being Ernst

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Some may know Oscar Wilde's play The Importance of Being Earnest from which I've modeled the title of this blog entry.  The play is a farce where obligations are shirked by assuming false identities.  There is no discussion of false identities in this blog but there is a false presentation of objective science on the part of Dr. Edzard Ernst as Wilde writes in Act 1

 I don’t play accurately – anyone can play accurately- but I play with wonderful expression.

In July the International Journal of Clinical Practice published a paper by Dr. Ernst titled: "Deaths after chiropractic: a review of published cases."  When I read the paper I noticed some obvious errors.  As opposed to some so-called science bloggers, rather than blog about it, I scienced.  (I read once where a scientist said that one should use science as a verb, one sciences.)  
I understand that Web 2.0 allows anyone to be a critic and possibly have great influence on public opinion (gee I am writing a blog about this).  However, one of the fundamental differences between the scientific endeavor and other domains of thought is that knowledge progresses though the publishing of ones findings in a public forum after peer review and then subject to the possibility of letters to the editor which help clarify or critique or add information to that publication.  When one submits a letter to the editor they are peer reviewed, as were the original manuscripts, and if one is using a bibliographic database such as PubMed the letters to the editor are hyperlinked to the record for the original manuscript so that people can find these important commentaries.

Here is a link to our letter to the editor on PubMed's web site.  Copyright issues prevents me from providing the letter to my readers.  We initially wrote a much longer letter but were informed after submission that the journal's maximum size is 500 words for a letter.  I will provide the added detail in this blog.
The paper the letter is in regard to is: Ernst E. Deaths after chiropractic: a review of published cases. Int J Clin Pract. 2010 Jul;64(8):1162-5.  In this paper Ernst's purpose was 

In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature.

In the results section of the paper he has a paragraph that is, to say the least, very interesting when one thinks of the purpose.   Herein he describes "the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims."  Ernst cites this with: "Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut.
25 October 2009.  There was never a hearing before the State Board of Chiropractic Examiners on October 25, 2009.  The hearing was in January of 2010 and because Long did not appear to under oath attest to his pre-submitted testimony it was, in accord with the procedural rules in CT not accepted and thus not part of the public record.  One wonders how does Ernst get this document when it was not public.  I have a copy as I was on the witness list and these pre-submitted testimony documents I was told were not to be made public until the board hearing.  


Anyone wishing to see the hearing where Long's testimony is discussed should go to the CT-N web site here.
In that same paragraph Ernst cites nine deaths from chiropractic  spinal manipulation that he found on a web site.  When I read Ernst's paper one name stood out in my mind, Kimberly Lee Strohecker.  I know a fair bit about Ms. Strohecker's very unfortunate death.  I wrote about it in a 2004 ethics article titled J'Accuse...! (I Accuse).  This article is about the death of Ms. Strohecker after a chiropractor got her to stop taking her anti-seizure medication.  At least the federal court barred the chiropractor from ever practicing chiropractic again along with prison and a fine.

Yes her death was the result of a chiropractor's actions but they weren't due to chiropractic spinal manipulation.  So I reviewed all the other people Ernst cited as dying from chiropractic spinal manipulation on the web site and discovered the Ms. Strohecker was one of 5 whose death might have been because of a chiropractors actions but weren't the result of chiropractic spinal manipulation.

What is the common feature of Ernst's citation of these deaths whose information or rather misinformation was obtained from a web site and the deaths reported by Long?  Neither of these data sources were from the scientific literature.  In his reply to our letter Ernst says "These cases were, however, merely added for completeness and not included in my total number of 26 cases reported in my review."  Completeness?  So adding people who didn't die after chiropractic spinal manipulation and weren't in the scientific literature adds completeness to a review of the scientific literature?

Now some reading this will say - gee that's picky.  Well the point is ones method must fit ones stated purpose.  Now if he had said in the discussion that there may be many more deaths after chiropractic spinal manipulation that aren't reported in the scientific literature and then cited these he would have at least stood on safer ground.  Still 5/9 cases he said were after chiropractic spinal manipulation weren't.  As we noted in our letter to the editor: "When obvious facts are wrong, the veracity of other facts, not as easily verified, must come into question."  Science works in part because we have to have faith that what people write in their papers is in fact the truth.  It is not truthful to say 9 people died when only 4 did.  Thus can we trust the rest of what Ernst tells us?

Also Ernst cites an event that never occurred, Long's non-testimony before the CT Chiropractic Board.  So again he cites something that is obviously not true.  Thus can we trust the rest of what Ernst tells us?  Some might say it is an honest error which if he was a newbie to scientific publishing I'd say give him a pass but I just did a PubMed search for Ernst E and found 1426 papers.  I don't think he can claim to be a newbie.

Ernst cites a paper by Dziewas et al as presenting another case of a person who died after chiropractic spinal manipulation.  However, one of the great features of modern electronic bibliographic searching technologies, such as  PubMed, which Ernst used, is that letters to the editor also are found with the citation for every paper.  When searching PubMed for Dziewas one finds a letter to the editor by Wenban.  Wenban reported that the treatment was not provided by a chiropractor and thus cannot be chiropractic spinal manipulation.  Wenban has detailed the commonality of wrongly ascribing adverse events of manipulation to the care of doctor’s of chiropractic. 

A couple of the letters to the editor note that Ernst missed in his discussion the study by Cassidy et al that investigated the association between stroke and seeking care of a chiropractic physician or a medical physician and found no excess risk for seeking care with a chiropractic physician.  I've blogged about this previously.   In Ernst's reply he says about Cassidy's study "it has been repeatedly criticised for being seriously, perhaps even fatally, flawed e.g. (8). The ‘inconvenient truth’ might thus turn out to be a 'convenient untruth’."  A long time ago I read an article that talked about somethings one can do to simply determine the validity of a paper one reads.  One of those is references.  Above Ernst says Cassidy's study has been repeatedly criticized for being flawed.  The key word is repeatedly.  This obviously repeatedly means more than once, which means that there must be more than one reference cited for that criticism.  In fact, I think most would agree that repeatedly probably means many more than one.  Well there is only one reference cited and what is that: Ernst E. Vascular accidents after chiropractic spinal manipulation: myth or reality? Perfusion 2010; 23: 73–4.

No it can't be the only criticism in the scientific literature (not the blogosphere mind you - this is science we are talking about here) that Ernst can find is his own (now you get the idea about the title for the blog).  Anyway, you mean to tell me that none of the critics of this study had the testicular fortitude to write a letter to the editor?  Cassidy's study was published in Spine and was part of the WHO's Bone and Joint Decade's Cervical Spine Task Force reports.  Well OK Ernst didn't see fit to write his critique in the journal it was published in, as my colleagues and I did about Ernst's paper.  You know those newbies to scientific publishing don't know that you should submit critiques to the journal it was written in.  Well you remember those 1426 citations to Ernst in PubMed just 204 are letters to the editor.  OK but let's look at his cited critique.  

Ernst E. Vascular accidents after chiropractic spinal manipulation: myth or reality? Perfusion 2010; 23: 73–4.

Don't search too hard for this in PubMed.  It's not there. The journal name is wrong.  I know newbies sometimes get their citations wrong especially when they don't know the journal too well.  Here is the proper citation.

Ernst E. Vascular accidents after chiropractic spinal manipulation: Myth or reality? Verlag Perfusion GmbH. 2010;23:73-4.

What do I know about Verlag Perfusion GmbH.  If you look at their web site you'll see it is a German publication and the first editor listed is...Ernst.  So I guess he's unfamiliar with the proper name for the journal.
Now to his critique.  I won't reproduce it here but instead suggest listening to Cassidy answer these questions as they were posed to him before the CT Chiropractic Board you can see his testimony here.

Ernst in his paper on deaths after chiropractic spinal manipulation also says that there is no benefit to spinal manipulation.  What's his reference for that.  You guessed it, his own narrative review.  Thus he ignores a growing body of systematic reviews showing benefit to spinal manipulation (1- 9)

There is one more item.  In that list of 1425 papers in PubMed written by Ernst E there are 299 systematic reviews of these I count 37 which there is only one author.   Of the 299 systematic reviews 17 are about the chiropractic profession.  Has a real fixation on us doesn't he.  Of the 37 systematic reviews with only one author 10 are about chiropractic.  Or to put is another way of the 17 systematic reviews about the chiropractic profession 10 are single author systematic reviews.  This is astounding.  Why?  Because standard practice in systematic reviews is to have at least two people.  What is considered to be the preeminent international group conducting systematic reviews, The Cochrane Collaboration never does any reviews with one reviewer.  Its just not done by almost anyone but...Ernst.  In fact from the Cochrane Handbook:

It is essential that Cochrane reviews be undertaken by more than one person. This ensures that tasks such as selection of studies for eligibility and data extraction can be performed by at least two people independently, increasing the likelihood that errors are detected. If more than one team expresses an interest in undertaking a review on the same topic, it is likely that a CRG will encourage them to work together.

 Well the self-importance of being Ernst is that he's the only expert whose opinion counts to Ernst.

SMP

1. Oliphant D. Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment. J Manipulative Physiol Ther. 2004 Mar-Apr;27(3):197-210. Pubmed record
2. Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadrado ML, Pareja JA. Spinal manipulative therapy in the management of cervicogenic headache. Headache. 2005 Oct;45(9):1260-3. Pubmed record
3. Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007 Oct 2;147(7):492-504. Pubmed record
4. Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW. Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research. J Altern Complement Med. 2007 Jun;13(5):491-512. Pubmed record
5. Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Spine J. 2008 Jan-Feb;8(1):213-25. Pubmed record
6. Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, et al. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008 Feb 15;33(4 Suppl):S123-52. Pubmed record
7. Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010;18:3. Pubmed record
8. Gross A, Miller J, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, et al. Manipulation or mobilisation for neck pain: a Cochrane Review. Man Ther. 2010 Aug;15(4):315-33. Pubmed record
9. Miller J, Gross A, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, et al. Manual therapy and exercise for neck pain: a systematic review. Man Ther. 2010 Aug;15(4):334-54. Pubmed record

Swine Poop - Swine Flu & Chiropractic II

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To quote President Reagan "there you go again". Once again a high profile chiropractor is there suggesting in a press release that chiropractic spinal manipulation is part of a reasonable flu prevention strategy. See my previous blog entry on Swine Flu & Chiropractic.

I know I could sit back and wait for the blogosphere of chiropractic critics to appropriately lampoon this press release. But then they would imply the entire chiropractic profession believes this but I won't be painted with that same paint brush.

I'll put it in the simplest language possible. This idea that "nerve interference" somehow leads one to be vulnerable to infection is swine poop. And the idea that one needs to see a chiropractor to make sure that there is no "nerve interference" so that one's children's immune systems will function at their best is swine poop, too.

As Max Planck wrote in 1936:

An important scientific innovation rarely makes its way rapidly winning over and converting its opponents; it rarely happens that Saul becomes Paul. What does happen is that its opponents gradually die out and that the growing generation is familiarized with the idea from the beginning.

Unfortunately, when it comes to chiropractic the opponents of rational thought and the scientific method within chiropractic seem to reproduce er proselytize before they die out. Thus, this pseudo-religious thinking persists within chiropractic medicine. Exposing this pseudo-religious thinking does not appear to force it underground. (1, 2) It seems that the Internet has allowed this form of lunacy to flourish as much as any other form of C.R.A.P. (convoluted reasoning anti-intellectual pomposity)

The most insidious part of this press release is that the writer has a legitimate degree in public health, an MPH. This might give the laity the belief that this is a legitimate idea. Likewise, one of those cited in the press release has an impressive sounding title as president of an organization with an impressive name. None of this provides any evidence that the press release actually presents valid information about the importance of the subluxation.

The fact that the CDC is cited also gives the illusion that this press release has some scientific merit. It only shows that the writer knows how to package this swine poop so it looks good. Or as was used so often in the last US presidential election, he's put lipstick on a pig. The central premise, go to a chiropractor so he/she can remove the subluxation which causes nerve interference which leads to a poorly functioning immune system is still swine poop.

Obviously the writer of the press release is intelligent. But as I noted in an earlier blog ideological immunity is not the domain of the unintelligent.

Now of course the author of the press release might posit that it is I who have the ideological immunity and just can't see the profound value to one's immune function by removing the ubiquitous nerve interfering subluxation. He might be right. Sometimes people with deviant thoughts are right: think the long road to that Drs. Marshall and Warren traveled before the role of H pylori in duodenal and gastric ulcers and stomach cancer was acknowledged.

However, as Carl Sagan wrote in Broca's Brain:

I believe that the extraordinary should certainly be pursued. But extraordinary claims require extraordinary evidence.

Clearly the idea that subluxations cause nerve interference which then reduces the effectiveness of the immune system is an extraordinary claim and it requires extraordinary evidence. I think as with any rational scientist I am willing to be shown to be wrong in my assessment and change my thinking. The growth of scientific knowledge is made by shattering the previous truths. BUT one won't shatter the current state of scientific evidence exclusively with the pronouncements or press releases of a self-professed expert. Show me the beef er the research that subluxations cause nerve interference and that it reduces the effectiveness of the immune system. Since we wrote our paper on the subluxation (3) I've not seen any evidence yet that our assessment was wrong.

Please prove us wrong by providing extraordinary level of scientific evidence (heck how about any valid scientific evidence). I'll tell you if those who believe this swine poop think that the first author on our paper, the late Dr. Joe Keating would be rolling in his grave if the evidence was presented, I'm here to assure you that I know he'd be cheering. Because Joe and the rest of the authors are basically saying put up or shut up. Please put up or shut up!

SMP

1. Mirtz TA. UNIVERSAL INTELLIGENCE: A Theological Entity in Conflict with Lutheran Theology. J Chiropr Humanit. 1999;9(1). free full text here
2. Mirtz TA. The question of theology for chiropractic: A theological study of chiropractic's prime tenets. J Chiropr Humanit. 2001;10(1). free full text here
3. Keating JC, Jr., Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF. Subluxation: dogma or science? Chiropr Osteopat. 2005 Aug 10;13:17. free full text here

Stupid Until Proven Intelligent - MD & DC Relations

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Around 1986-7 I was the medical director for a track meet at West Point. At that time I was in charge of all medical care for all of the Metropolitan Athletics Congresses events. I must have worked at 40-50 track and cross country events a year.

Whoever was a top US 100m high hurdler fell and hurt her leg. The pain was on the lateral side of her lower leg. A tuning fork test suggested an unusual fracture one of the fibula. The tuning fork test is where one puts a 128Hz turning fork on a bone with a suspected fracture (not right over the site of injury) and the vibration is supposed to irritate the fracture side and cause pain.

I drove this woman to the base hospital and spoke to the admission clerk, reporting a suspected fibular fracture. The attending was standing nearby and overheard me. He said, “don’t you mean tibia?” I replied, “no, fibula.” He asked why I thought fibula. As I said this is not a common fracture.

I said location of pain and a positive tuning fork test. That of course provoked questions about the tuning fork. I said that it was a standard on-field screening test in sport medicine.

MD: “Sports medicine? That’s a specialty?”

Me: “I’m certified” {I was a CCSP (Certified Chiropractic Sports Physician - except due to NYS bizzar rules I was supposed to call myself a Certified Chiropractic Sports Practioner}

MD: “I didn’t know there were fellowships in that?”

Me: “I did post grad training”

He then asked if I could show him how to do it on a woman just brought in by ambulance. She crashed on the base ski run. He had to get a nurse to unlock the cabinet with the tuning forks. They had the box set with every frequency. I took out the 128Hz and showed him how to use it. Later after my athlete’s radiographs came back negative we talked some more. He asked what hospital I work at and then I said, “I don’t, I’m a chiropractor.”

Lindsay Rowe, DC, MD taught me this "technique" to deal with medical prejudice towards chiropractors. He said that to many MDs you are stupid until proven intelligent if they know you are a chiropractor. So prove you are intelligent and then let them know you are a chiropractor. I’ve used it often to great effect.

The example Lindsay gave me was that before he went back to get his medical degree, he used to travel the US. Wherever he was he'd call the local medical school and try to speak to the head of radiology department. On the phone he would introduced himself as a radiologist from NZ with interesting cases. Lindsey is a board certified chiropractic radiologist. {BTW two studies have shown that chiropractic radiologists (DACBR) are as good as anyone else in reading skeletal films.(1, 2)} If he got to meet with the radiologist they'd play what I call, "stump the radiologist."

Then when they were done trying to stump each other he’d reveal he was “only” a DC. Lots of surprised looks. He was invited to give grand rounds a few times and audience was only told what his training was at the end. Most couldn’t believe it because of course we’re all dumb as door-nails.

I've used this technique for many years. Fortunately, I don't run into such overt prejudice as often as I once did. My favorite example was the MD at a cocktail party who upon hearing I was a chiropractor dropped my hand, mid-handshake, spun on his heels and walked away without a single word.

Because of my work with the ING New York City Marathon and the New York Road Runners I often come in contact with MDs and haven't had that kind of thing happen. I guess that means my profession is moving more into the mainstream of health care, but we have work yet to do to be completely in mainstream health-care.

SMP

1. Taylor JA, Clopton P, Bosch E, Miller KA, Marcelis S. Interpretation of abnormal lumbosacral spine radiographs: A test comparing students, clinicians, radiology residents, and radiologists in medicine and chiropractic. Spine. 1995;20(10):1147-54.
2. de Zoete A, Assendelft WJ, Algra PR, Oberman WR, Vanderschueren GM, Bezemer PD. Reliability and validity of lumbosacral spine radiograph reading by chiropractors, chiropractic radiologists, and medical radiologists. Spine. 2002 Sep 1;27(17):1926-33; discussion 33.

Cultural Authority and the Chiropractic Profession

Cultural authority: an editorial by John M Ventura, DC

In the excellent text, Surviving in Health Care by Dieter Enzman, MD, (Mosby, 1997) a working definition of cultural authority is proposed, and more importantly, a strategy for achieving cultural authority is outlined.

The ability of medicine to achieve cultural authority in the early 1900s was a “confluence of factors encompassing professionalism, the Industrial Age and an incentive-skewed market.” What may be most remarkable, given the almost exponential growth of health care costs through the 20th century, was the duration that medical cultural authority went unchecked. Medicine was said to have achieved “professional sovereignty.” Whether consequential to, or simply a reflection of, the constraints of managed care, medicine has lost some of its authority. Dr Enzman’s book is an effort to place medicine back on a path to achieving a new measure of cultural authority. The relevance for the chiropractic profession is that cultural authority is defined in a manner which may be pragmatically applied, and Dr Enzman has a lot to teach the chiropractic profession with his recommendations to the medical profession. If and when the chiropractic profession takes on this challenge may be the determining factor between merely surviving into the 21st century versus thriving. Our future is not guaranteed. A collective effort of well thought out strategies will be needed to implement the requirements for achieving cultural authority.

Cultural authority allows a profession to define its own professional truth. The profession decides what is fact and what is fiction and the public accepts the rules set forth. Cultural authority is characteristically unique in “having authority without having to overtly exercise it” as opposed to social authority, which is the ability to command people. There are two primary features of cultural authority: competency and legitimacy. Competency is a demonstration of technical expertise. Legitimacy is achieved by using competency to advance public health.

Competency requires validation by peers and rational foundation (scientific basis). A key feature of this technical expertise is that competency must be gained as a group - not individually. The beginning of shared professional competency for medicine was achieved by standardized training, based upon the principles of science. An intended benefit of professional competency is that when any individual member of a profession gives advice, that advice is representative of “shared professional standards”, not the idiosyncratic recommendations of a renegade practitioner. Professional legitimacy includes collegiality, cognitive approach, moral attributes. You be the judge of how well the chiropractic profession has demonstrated collegiality, a cognitive approach to health issues and high moral attributes.

If we can agree that achieving cultural authority is in the best interests of the chiropractic profession (the ability to define our own professional truth), then we might ask what steps the chiropractic profession can take to achieve some measure of cultural authority? As was the case for medicine, chiropractors need to demonstrate competency and legitimacy to the public. And this must be done by the collective efforts of the entire profession.

Dr Enzman describes the following for the medical profession to regain some its lost cultural authority:

• Continually demonstrate competency to the public; proof of training and licensing is no longer sufficient
• Provide ‘credible data’ to validate medical claims and recommendations
• Focus upon outcome analysis, a ‘crucial’ factor for the medical profession
• Standardization of practice patterns, both regionally and within each specialty
• Standardize the lexicon, which demonstrate peer validation of competency
• Focus upon the societal value of health, not upon reimbursement
• Avoid ‘filtering and restricting information available to patients’; embrace the informed consumer(patient)
• Be leaders and therefore, be honest, at all times

There is a theme that surfaces in the above recommendations of Dr Enzman – patient centered, evidence based care. Patient centered, evidence based care needs to be the mantra of the chiropractic profession. The following represents a partial list of the steps necessary to place the chiropractic profession on the road towards cultural authority:

• Standardize the training of chiropractors using principles of science, best available evidence, and consensus (though the consensus must be based upon the previous two attributes).
  
• Raise the standards for admission to and graduation from chiropractic colleges, and raise the standards for licensing
  
• Standardize the chiropractic lexicon
  
• Affiliate chiropractic colleges with established and proven universities so that resources (faculty, research facilities, etc.) can be shared
  
• Define the most fundamental aspects of chiropractic care: subluxation (in a quantifiable, testable manner); treatment frequency and duration for given clinical presentations;
• Standardize clinical outcome measures to validate responses to chiropractic care (“credible data”)
  
• Increase funding towards chiropractic research
  
• Encourage attendance at research symposiums
  
• Professional unity: one primary organization to represent the profession politically; all chiropractic colleges embrace and implement collectively determined standards of care;
  
• Patient centered, evidence based care is the foundation for training of chiropractors
• Reduce variation of approaches to diagnosis and treatment within the profession
• Increase training in all manner of public health issues for chiropractors
• Encourage chiropractors to become involved with APHA

The public perception of the chiropractic profession, by and large, is not one of trust. In 1990, the McLean County (Illinois) Chamber of Commerce's Professional Committee surveyed a population of people (12% of which were chiropractic patients) with the following results: only stockbrokers scored lower on a scale of trustworthiness than chiropractors, over 45% of those surveyed felt chiropractic ethics were below average. In the Canada Speaks survey, held in 2002 and again in 2006, chiropractic trustworthiness improved from 15th place to 12th place (49% of those surveyed felt chiropractors to be trustworthy), but still well below medical physicians(80%) and nurses(87%). Clear demonstrations of competency and legitimacy, by the profession as a whole, are required to increase public trust, and therefore, increase the cultural authority of the chiropractic profession.

Two views of chiropractic

The Chicago Tribune published a story about chiropractic today which shows the dichotomy within the profession and they have squarely come down on the side of the evidence based approach to chiropractic. They quote Dr. Don Murphy with whom I co-authored a paper on making chiropractic more mainstream using podiatry as a model. (1)

They also have suggestions on picking a chiropractor:

• Be wary of those who say spinal manipulation can cure whatever ails you
• Ask whether exercise is part of the program.
• Ask friends and relatives for recommendations.
• Get more than an adjustment
• Shop around

I've blogged on choosing a good chiropractor before. I agree with the recommendations that Trib wrote except for getting a recommendation. It is obvious that there are people who have become indoctrinated by the quasi-metaphysical, pseudoreligious, pseudoscientific branch of the chiropractic profession. These people have been trained that spinal manipulation will have some profound affect upon their overall wellness above and beyond the function of the spine, other joints or the musculoskeletal system.

SMP

1. Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF. How can chiropractic become a respected mainstream profession? The example of podiatry. Chiropr Osteopat. 2008 Aug 29;16(1):10. (this is a free full text paper just click on the link)

Chiropractic In the News Downunder

The Australian TV show Lateline recently did a piece on chiropractic. This was motivated by the British Chiropractic Association's libel law suit against Simon Singh. On balance I think this was pretty good news story. From when I began in the profession, in 1979, as a student at Texas Chiropractic College and for a long time after that it seemed to me that the media were just hatcht men for the AMA. Since Judge Getzendanner's 1988 decision in the Wilk v. AMA law suit the media has been kinder.

The Lateline video includes interviews with Bruce Walker, DC, MPH, DrPH. and Chris Maher, PhD. Dr. Walker is the editor in chief of Chiropractic and Osteopathy an open access, peer-reviewed online journal that aims to provide chiropractors, osteopaths and related health professionals with clinically relevant, evidence-based information. I am an one of four associate editors for C&O. So often it seems that print or video media edit away the substance of a interviewee. I think Dr. Walker's interview was treated fairly and he gets across his point about the evidence regarding chiropractic care.

Dr. Walker notes that chiropractic care should primarily be for the musculoskeletal system. In C&O I am a co-author of a couple of papers that suggest that chiropractors should mostly be non-surgical spine specialists because substantially what we do is spine care.

Dr. Maher, who is a physical therapist discusses recent research that found that manipulation is no better than standard medical care. Unfortunately his use of the term manipulation is unusual. Only 5% of the subjects in this study actually had manipulation and the rest had mobilization as a treatment. Thus the study does not actually evaluate spinal manipulation. with Dr. Jeff Hebert of the U of Utah, I have published a letter to the editor pointing out this inconsistency.

There is also an interview with an MD about stroke in which he again ignores the most recent research showing that manipulation does not cause stroke.

SMP

A NICE approach to treating low back pain

NICE which is the UK's National Institute for Clinical Excellence has just released guidelines for treating low back pain (LBP).

The first recommendation is to promote self-management. This means to suggest to patients with LBP to exercise and try to continuing doing ones normal activity, as possible. The next one is pain medication - first acetaminophen. The final recommendation is exercise or manual therapy (i.e. spinal manipulation) or acupuncture.

Another interesting feature is what the guidelines proscribe. All of the following are treatments/diagnostic tests that are NOT allowed (because they either don't work or aren't needed):
Medical/Surgical treatments

• SSRIs for pain management
• Facet injections
• Radiofrequency facet joint denervation
• IDET (Intradiscal Electrothermal Annuloplasty)
• PIRFT (Percutaneous Intradiscal Radiofrequency Thermocoagulation)
  

Physical therapy

• Laser therapy (AKA Cold Laser)
• Interferential electrical stimulation
• Therapeutic ultrasound
• TENS (another kind of electical stimulation)
• Lumbar supports or belts - back braces
• Traction

Diagnostic tests

• Plain film x-ray under any circumstances
• MRI to be offered only to rule out red flags or for surgical referral
• I think of an MRI for a a back pain patient, a road map for a surgeon. Keep that in mind if you are pushing your doctor to get one.
• Red Flags are signs of:

• Spinal cancer
• Cauda equina syndrome
• Infection
• Ankylosing spondylitis or another inflammatory disorder
• Fracture

Of course as I noted in previous blogs, it is likely that your health care provider will ignore these recommendations and do what they have always done, even if the scientific evidence is that it is not effective.

See:

• Treatments that don't work
• Resistance to using the best treatement
• Ultracrepidarian Doctors and Back Pain
  

These new guidelines are is not particularly new but nice to see.

SMP

Ye Of Little Faith - In Chiropractic That Is

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.

I haven't yet received any anonymous hate mail, such as when my colleague Randy Ferrance, DC, MD and I co-authored one of my ethics columns for Dynamic Chiropractic on vaccinations, entitled What's Good for the Goose Is ... Ethics and Vaccinations. (BTW I think we would write this differently now due to a change in the evidence on stroke and chiropractic.)

That column resulted in such an outpouring of venom directed at Dr. Ferrance and me that I wrote a column about Argumentum Ad Hominem (ad hom for short) - which is to attack the person not their argument. For some reason, I do not completely understand, many people in my profession will resort to ad hom rather than find the flaws in an argument they think is wrong. To quote from my Dynamic Chiropractic article: "This is the most feeble reply one can make and generally reflects poorly upon the person who does it. Those who are not biased see this as having no probative value in the argument, and it signals that the person using that reply has no valid counterpoint and is not acting professionally."

Lack of Faith

Some think that my last blog entry shows I lack "faith" in chiropractic. Well clearly I do lack faith in chiropractic, just as I lack faith in medicine, physics, mathematics...

I think that faith is not an appropriate word to describe ones association with ones profession. No one would ask a mathematician, "do you have faith in math?" However, one might ask a member of the clergy do you have faith in your religion. This is because one is obligated to have faith in a religion. There is no other method for one to accept the tenets of a religion, as there is no method to determine the validity or lack of validity of those tenets. Faith is a belief that does not rest on logical proof or material evidence.

I do have faith in the epistemology (a subset of philosophy) inherent in science (i.e., skepticism, empiricism and determinism). Science is an epistemological theory about how one acquires knowledge and cannot be validated using the scientific method. Using science to validate science is a tautology. Thus one must have faith that science is a good method to discover how things function. So far it has worked out pretty well. You are reading this because of thousands of scientific discoveries that ultimately lead to blogging (not sure this is science's best day).

Chiropractic is a health care science and thus starting with my faith in science, I am forced not to have faith in chiropractic but to conclude, based on the available science that chiropractic is or is not a useful method for the care and prevention of human illnesses or maladies.

Given the above, I have found evidence that I find to be compelling to make me conclude that chiropractic is an extremely valuable method for the care and prevention of human illnesses or maladies. I will not blindly have faith in chiropractic or anything else, I will question it constantly, that I believe is my job as an academic.

Narrow view of chiropractic

One chiropractors suggested that my blog entry shows that I have a narrow view of chiropractic and that I implied we should stick to headaches, low back and neck pain. I wrote:

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.

If one wants to see a good review of what evidence there is take a look at the Council on Chiropractic Guidelines and Practice Parameters (CCGPP)'s web site. One could also look at the Cochrane Collaboration and search for manipulation or chiropractic. Then there are some conditions that there is a complete lack of evidence. Such as preventing the flu.

As you can see from my long list of quotes on this blog, I am a fan of quotes. Two from Carl Sagan are illuminating in this regard.

"Absence of evidence is not evidence of absence"
- "The Dragons of Eden"

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:

"I believe that the extraordinary should certainly be pursued. But extraordinary claims require extraordinary evidence"
- " Broca's Brain"

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.

As I wrote before it only serves to marginalize our profession by making us look like we are unscientific.

What I Was Taught In School

Another comment was about how a doctor wanted to believe what he was taught in chiropractic school about an adjustment improving immune function. As I tell my students often do not believe what I tell you. Go to the scientific literature yourself and find the evidence. And if you find that the evidence shows. I would be happy to eat my words that an adjustment will help prevent the flu so show me the scientific evidence.

CDC

One comment about my blog entry was that I suggested that people look at the CDC's web site for advice about the swine flu. The problem with that is supposed to be that "the first thing that website site [CDC's] says is to get the flu vaccine to prevent the flu. We all know that the flu shot is a shot in the dark and far from an exact science"

The problem with this statement is that the CDC does not recommend a flu vaccine for the H1N1 but for seasonal flu. In fact, they say that there isn't a vaccine for the H1N1 flu. Here is what they recommend:

1. Avoid close contact - Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too.
2. Stay home when you are sick - If possible, stay home from work, school, and errands when you are sick. You will help prevent others from catching your illness.
3. Cover your mouth and nose - Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick.
4. Clean your hands - Washing your hands often will help protect you from germs.
5. Avoid touching your eyes, nose or mouth - Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.
6. Practice other good health habits - Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food.

I know that no chiropractor would have a problem with these recommendations. What does this tell us with the complaint about my suggesting use the CDC for information. It tells us that the person who was criticizing me never even clicked on the links to the CDC to see what the CDC actually recommended. Just as they inferred I had a narrow view of chiropractic, without reading carefully what I wrote, they assumed that the CDC would recommend the flu shot.

As I wrote in the swine flu blog: "Overstating what we know only serves to decrease our credibility." In this case making pronouncements that, all easily available evidence, refutes doesn't do great things for ones credibility either.

SMP