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

Katz and dogma

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.

Dr. Katz had presented an anti-chiropractic diatribe at McGill which is "so full of fabrications, extrapolation and cherry-picked use of the literature that his presentation really should be prefaced with a warning that this is fiction."

I was asked a question on the discussion board after posting the comment above (and more) about "high neck manipulation." I cited the recent literature on the topic:

Cassidy JD, Boyle E, Côté 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;33(4 Suppl):S176-83.

This is rather compelling evidence that the association seen in previous studies between cervical manipulation and vertebrobasilar stroke was actually an association between vertebrobasilar stroke and seeking the care of a health care professional. We know this from Cassidy et al because the association between stroke and seeing a chiropractor was identical to the association between stroke and seeing a primary care physician (PCP) AKA a medical doctor. Thus manipulation was not associated with stroke just seeking care was.

Then Katz joined in the discussion:

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

Here is my reply:

Re: Re: High Neck manipulation Posted by Stephen on Aug 02, 2008
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.

If anyone is interested in the whole exchange please go to McGill's web site

Again if anyone is interested in the best evidence on chiropractic stroke read the study by Cassidy et al

SMP

An inauspicious beginning

As they say a journey of a million miles begins with one step.

However, what motivates me to start writing results in an inauspicious beginning for my blog. I found out that one of my former students just pled guilty on Jan 22, 09 to insurance fraud

This makes me ponder what makes someone steal, what fundamentally is so little money (think Madoff ponzi scheme). I know that some will read this and say half a million dollars is a lot. But think about this. Since that money was stolen by committing insurance fraud, the money was reported to the IRS by the insurance company. Thus, after all the taxes this might have resulted in a net of $300K. It appears that the fraud was committed from 2005 - 2008. Thus, $100K/year.

I know that this is a little more money than the median family income in Simsbury, CT where the fraud took place. I say it is not that much money because of how great the downside risk was. In this case, the doctor not only has to repay the money but could end up going to jail for 10 years and could pay up to a quarter of a million dollars in fines. As a gamble the downside risk was way too high given the pay-off ($300,00).

Not that any amount of money would motivate me to steal but at least if he'd stolen many millions or billions he could have squirled away enough money in an off-shore account that when he got out of jail he'd be able to live well in a third-world country. In this case, I suspect when he gets out of jail he will have no money and no real prospects to earn money. If he has a family I suspect they are financially ruined. They might loose their home (as many honest people are right now) but at minimum they will loose, what no doubt, was a comfortable lifestyle.

This is a sad outcome for the doctor's family (who I am sure were innocent) and all who knew him. If I could have prevented the fraud, I would. However, given that the fraud actually occurred, I am actually glad that it was discovered and justice prevails.

For the chiropractic profession, fraud like this only serves to erode the profession's social and cultural authority. Thus as a chiropractor I condemn this fraud and applaud the FBI and the US Attorney's office for this successful investigation and prosecution.

SMP

Perles of Wisdom Or NOT

Whether the content of this blog are words of wisdom or not will, of course, depend upon ones point of view.

As they say "great minds think alike." But I like to keep in mind the corollary"fools seldom differ."

SMP