Preventing vs. Postponing - will health care reform save money

I'd love to say that the what you'll read below, about how health care reform, specifically preventive health care, is my work. It is not. It comes with permission from a friend, colleague and brilliant chiropractor.
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Previously I posted a note that suggested that the Congressional Budget Office (CBO) will be the linchpin in health care reform. That Office will be required to calculate the budget implications of any reform package. And if that calculation reveals that the reform is underfunded by about a trillion dollars (as it is right now) this will create insurmountable problems to its passage.

Nervous congressional Democrats are trying to figure out how to circumvent the CBO. One strategy is to bypass the CBO and rely on the administrations calculations from their Office of Management and Budget, a sort of parallel organization to the CBO, the difference being that the CBO can be relied up to come up with whatever number is needed to pass the legislation. One of the areas of contention between the CBO and the OMB is how much to credit preventive care as a money saving element of reform. The CBO credits it with zero dollars and the OMB with hundreds of billions of dollars. Here’s a news item from yesterday that highlights this:

Sen. Barbara Boxer said she would not feel obliged to abide by CBO’s work if it does not take into account savings from preventive healthcare and other reforms.

"I haven’t seen [the CBO score] but if they don’t take into account prevention, I certainly won’t. I will not follow it — we just heard from the CEO of Safeway, who said his insurance costs went steadily down since they instigated incentives for prevention.

Any scoring that doesn’t understand that, is not relevant to the way we work.”

Who’s right, the CBO (zero savings from prevention) or the OMB (hundreds of billions saved from prevention)? The CBO is correct (zero savings). Here’s why—

It is endlessly repeated by politicians, public health advocates, physicians, TV talking heads that we spend a huge percentage (the figure 30%) is often used to treat “preventable” illness. What is usually meant by this are those chronic diseases that are driven by lifestyle—diabetes, heart disease, COPD, smoking-related cancers etc. This is undeniable. This set of conditions easily accounts for at least 30% of our health care budget. There is in fact an exploding industry devoted to both the primary and secondary prevention of these problems, the so-called Disease Management and Wellness industry. These programs target the high risk population and attempt (with varying degrees of success) to change behavior and thereby reduce health care costs. It can be shown that well engineered and properly implemented programs of this type can indeed pay for themselves and even return savings in the form of reduced health care costs. So what’s the problem? If a company of, say, 500 employees can do this, why can’t be implement this on a scale of the entire US population?

Here’s the problem. If I’m an employer considering such a program one of the questions I have to ask is, “Will I, as the employer, realize the savings from such a program? So what if I spend money to get an employee to quit smoking and then he leaves this job to work somewhere else…I’ve just financed the savings for some other company.”

And indeed if a particular company has a high employee turnover rate these programs will not save money. The reduced health care expenditures have to occur under the watch of the employer who paid for the program for this to make sense. There are algorithms that will tell you if a particular employee turn-over rate will or will not allow for such savings. From the employers perspective the healthy employee has to remain in his employ to realize the savings. The key word here is “perspective.” We must always ask from whose perspective are we calculating health care costs or savings.

When doing the calculations that the OMB and CBO are doing the correct perspective from which to view this is the societal perspective. We are interested in the total net costs or savings in our entire health care system for all persons at all stages of their life. An individual might leave and employer but he never leaves the umbrella of the societal perspective.

Ah, but this is good news, you might think. Any ex-smoker, reformed couch potato or otherwise newly healthy person is always under the societal umbrella and thus all savings will eventually accrue at a societal level. Ergo, we save billions.

But this societal perspective is precisely the problem. Let’s consider several scenarios from both the employer’s perspective and from the societal perspective:

Scenario 1. Joe Blow is a 32-year old smoker who works for the Megatron Corp. Joe says the hell with it. I like cigarettes. I’m not quitting. Joe stays with Megatron his whole career. He experiences a variety of smoking-related illnesses (chronic bronchitis) and eventually dies of lung cancer at age 59. The Megatron Corp. spends a good deal on money on Joe’s health care over the years and eventually pays for the the futile treatment of his lung cancer.

Scenario 2. The Megatron Corp. implements a worksite wellness program that includes a tobacco cessation program. After couple of failed attempts Joe eventually quits smoking at age 36 and continues to work productively for Megatron Corp until he retires at age 62. During his employment Joe enjoyed generally good health and had only routine medical care with the exception of knee surgery to repair the ligaments he tore skiing. (Joe really did reform himself…he became an avid outdoorsman, hiker, skier.) The couple of hundred dollars Megatron spent to get Joe to quit smoking saved many tens of thousand of dollars in related health care costs.

Success!! Prevention works. It saves money. At least from the employer’s perspective. But from a societal perspective Joe’s story continues:

Joe enters retirement (and Medicare) in good health. He remains active, but eventually that repaired knee gets worn out and he gets a total knee replacement. By his mid-70s one of his hips is gone and that gets replaced too. But Joe is still going strong. Soon he needs cataract surgery and some lens implants as well. Joe is becoming all spare parts!! In his late 70’s he suffers a mild stroke…his skiing days are over. Two years later he’s diagnosed with colon cancer. Surgery and radiation go pretty well, but one never knows.

What finally gets him, though, is dementia. After a few years his children realize that Joe can no longer care for himself and his children put him in a long-term care facility. He doesn’t last long there, only 3 years, an Joe dies at age 83. Not that anyone is keeping track, but Medicare ended up spending $400k on Joe during his retirement.

Alright, this is all make-believe, but what this illustrates is this: From a societal perspective, prevention of chronic illness is impossible. All that is possible is to postpone chronic illness. Every case of lung cancer that is prevented exposes society to future cases of colon cancer, stroke, Parkinsonism, dementia, and well, everything else. Every premature diabetes-related death that is prevented exposes society to future cases of breast cancer, skin cancer, kidney failure, liver disease, and well, everything else.

Now of course, if we can prevent lung cancer and diabetes and emphysema and other chronic disease, we should. This is the point, after all. But we cannot do so with the illusion that somehow we will never end up spending boat-loads of money as we age and become infirm. In nearly all cases, preventing early chronic illness will end up costing us far more money to treat later-life chronic illness. But that’s the price of success.

Anyway, watch for the battle between CBO (who are professionals) and the OMB (who are political hacks) on this.
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As one who teaches a class in wellness, I certainly thought that prevention saved money. As you can see from what my colleague has written, it all depends upon the perspective of who pays for the prevention on who saves money. Obviously, preventive measures that are effective: proper diet, regular exercise, no smoking, use of seat belts, safe sex, should be implemented.

I often hear people say we all have to die sometime. In fact, someone trying to get me to buy tobacco in Mexico a couple of weeks ago said that to me. But the reduced disability, prolonged and productive life is good for each of us, no?

Frankly, my mother’s death at age 66 from cigarette smoking deprived my children of a grandmother. I was very fortunate that my own grandmother and great grandmother died when they were in their late 90s and early 100s, respectively. I miss them both but have vivid memories as they both died when I was an adult. My children don’t have that. Likewise, my mother’s early death meant she didn’t see my daughters grow to become a bat mitzvah, let alone married and have children.

Thus, I think the benefits outweigh the economic cost and we do need to implement more and better prevention programs. If it takes the deep pocket of the government to do it so be it but let's be honest about the costs unless do we really need a white lie is needed to get the reform package passed.

SMP

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.

Chiropractic Business - What is the nature of the business

A few friends of mine sent me a great book to read by Jeff Jarvis, What would Google do. There is a chapter in the book that talks about what is the nature of your business and how most people don't know what business they are in.

Approximately 25 years ago a NYRR volunteer (non-medical) I was friendly with explained this concept to me. He worked in fleet rentals for Hertz and asked me what business is Hertz in? The obvious answer, which I said, was renting cars. He told me I was wrong. Renting cars wasn't a profitable business. The cost of advertising, reservation system, rental counters at airports, buses, lots, carrying charges on the cars and their maintenance was barely offset by the actual money received for the rentals. Thus, one can't really say that Hertz was in the car rental business.

He said that what Hertz did was the largest manufacturer and seller of used cars. That was because they sold the used car for more money than they bought the new car for but couldn't do this until it was used "enough." Those of us who rented from Hertz actually paid for the privilege of working to turn the new car into a used enough car so that Hertz could sell the used car we made back to us for a profit.

He used this as a metaphor for his belief that most companies have no idea what business they are in. This made me think about what business I, a practicing chiropractor was in.

As I said I was reminded of this by Jeff Jarvis' book WWGD. The question then is what business is a chiropractor in? Some in my profession would say that we are in the subluxation removal business. This is delusional. How many people who have never heard of chiropractic wake up and say, "gee I wish there was someone who could get rid of these darn subluxation." The obvious answer is no one. Now that could of course be because they didn't know the word. However, there isn't a vernacular term for the subluxation as is true with other medical conditions. People say that someone broke a bone, and might not know the term fracture. Or they'll know heart attack or stroke rather than myocardial infarction or cerebral infarction.

Some of my colleagues would say, but a person dying of heart disease, of cancer or diabetes or... does not know that they have these diseases until they become symptomatic. That is true. However, at this point in time my profession, chiropractic, has yet to find a valid or even reliable way to find a subluxation. Nor have we found that getting rid of them helps people or that a person with a subluxation is less healthy then a person without one.

On the other had there are valid and reliable tests for heart disease, cancers and diabetes. We also have good evidence that left untreated these diseases do kill and that with treatment patients can sometimes live much longer lives (depending on the specific disease, the stage at diagnosis).

Clearly there is good scientific evidence that spinal manipulation is a beneficial intervention. While the physical therapy profession and others have newly discovered the benefits of manipulation, after years of saying it was quackery, those benefits are found without the metaphysical aspects of the subluxation dogma some in chiropractic espouse.

Then what is a chiropractic business? Generally it is non-surgical spine care or another way to think of mainstream chiropractic is it is the non-surgical management of spinal pain disorders.

I say management because that might mean that chiropractor does all the diagnosis and treatment or it might involve an integrated approach where the doctor of chiropractic works to lead a team or be a member of a team whose goal is the improvement in a patient's spinal function.

Do chiropractors' management skills extend beyond the spine? Depending on the doctor the answer is yes. My own practice in NYC in the 1980s was mostly lower extremity conditions as most of my patients were runners. But I also treated a lot of cyclists, swimmers and triathletes so also saw a lot of upper extremity problems too. I was a sports chiropractor and thus had competency that extended beyond the spine.

Some of my peers think because I was a co-author on a paper titled: Chiropractic as spine care: a model for the profession that my co-authors and I believe that chiropractic has no place outside the spine. This is very far from the facts of our paper. We just believe that as a profession all of us need to, at minimum, be competent in non-surgical spine care and the profession needs to maintain the spine and its non-surgical care as the basic minimum competency. And come on when the public thinks of a chiropractor what do they think of? SPINE. I travel a lot and when people find out I'm a chiropractor they either grab their neck or the their back and say can you help me. No one has ever said - "oh I have a subluxation." That is despite the fact that so many chiropractors talk subluxation 24/7 even on the web.

An analogy. My family has had two occasions to consult oral surgeons. These doctors are trained as dentists. However, they do not have additional professional training at medical doctors. These dentists do not fill any cavities, or do other restorations that we ordinarily associate with dentists. Yet they are dentists. But the American Dental Association does not market dentistry as oral surgery. Still while these oral surgeons do not have training as medical doctors they do have additional training beyond what a general dentist has.

Likewise, for a chiropractor, such as myself, specializing in sports chiropractic there is the need for post-graduate training without that then the general chiropractic physician is a non-surgical spine specialist. Not a bad business to be in when over 90% of people will get back pain sometime in their life.

SMP

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)

Malpractice 2

In a recent blog I commented on a NY Times op-ed on malpractice, Liability = Responsibility. The author, Tom Baker based this on a paper from the NEJM by Studdert et al (1) Studdert et al analyzed 1452 closed malpractice claims from 5 malpractice companies. They used an expert panel to determine if for each claim if there was an injury and if it was due to error.

We have heard for years Republicans and other conservatives bleating on and on that the problem with malpractice is frivolous suits. Well these researchers found that only 3% of all the claims involved plaintiffs without any injury. These are frivolous suits.

Of the 97% of closed malpractice claims with an injury, 37% were deemed to not have been caused by physician error and 28% resulted in payment. Based on total amount paid on these cases and legal costs in all the cases where there wasn't an injury or error Studdert et al determined that 13% (excluding close calls on determination of error) to 16% (including close calls) of the total costs of these 1452 malpractice claims involve cases that might be removed from the system with some kind medical malpractice reform. Thus, reform would not result in substantial savings.

On the other side of the coin 27% of cases where an error occurred did not result in any payment to the plaintiff (which is almost equal to the percent of cases with no error that resulted in payment to the plaintiff). Thus in this study 236 (16%) people who were injured due to medical error received no compensation and 151(10%) received compensation when they shouldn't because there wasn't an injury or their injury wasn't due to a medical error. Thus, the correct outcome (payment or no-payment) occurred in 3/4 of all cases reviewed.

I think the real problem is that we have a fault based system. If we switched to no a fault system with universal health care we would be better off.

As a no fault system providers would willingly share what occurred that resulted in the injury. This would allow others to learn from the mistake. This is how the aviation industry works. A pilot or air traffic controller that reveals an error, regardless of the outcome (e.g. a crash or no harm) won't be disciplined if they disclose the error within a short time (I believe it is 2 days). Thus, everyone can learn what went wrong. Right now errors are discussed in private conferences in hospitals but not disseminated widely for everyone to learn from.

Secondly if we had universal health care then people wouldn't have to sue to get money to pay for their care after they were injured. Studdert et al found that it took the average claim five years to be closed. That's a long time for someone to wait to get money to cover their medical expenses injured due to an injury that was due to medical error.

We need change in the malpractice system but it should be based upon a knowledge of what's wrong rather than people's biases which all I have heard until now.

SMP


1. Studdert DM, Mello MM, Gawande AA, Gandhi TK, Kachalia A, Yoon C, et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006 May 11;354(19):2024-33.

Rationing Health Care

The 3rd rail in the discussion about health care reform is rationing. Princeton ethics professor Peter Singer presents a cogent argument for the need for rationing in a NY Times Magazine article, Why We Must Ration Health Care.

I won't rehash his arguments except to say that though the use of a joke about prostitution he notes that this is all about a negotiation about how much we will spend for a particular outcome. Britain’s National Institute for Health and Clinical Excellence (NICE) which I have blogged about earlier regarding treating low back pain. NICE has said that for a year of extra life they suggest spending up to approximately 49 thousand dollars. I know this seems harsh but as I said it is about a negotiation. Most would agree that 10 million dollars is too much for our economy to pay to extend a life one year. Obviously, Bill Gates or others will limitless finances are free to do that but clearly no country can afford to spend that much money for only 1 year of life. Everyone would agree that spending $100 to extend a life one year is easily worth it. So the difference between these two are just a matter of negotiation.

One fact that Singer ends with is a refutation of the conservative argument that health care reform will result in the US getting stuck with health care that the Britons or Canadians have, as if that is a horrid outcome. Singer presents the results of a Gallup poll on how happy are US, UK and Canadian citizens with their health care. Seems that if this poll is definitive, we in the US would be fine with a UK or Canadian style of health care, not that those are the only models to choose from. I guess the conservatives hope that we'll just listen to their fallacious arguments and believe them. Fear mongering is a live and well on the right.

Details on the Gallup poll can be found here.

SMP

Malpractice

In the NYTimes (what else?) there is an interesting op-ed about malpractice, Liability = Responsibility. Knock on wood I've never been sued but I have taught risk management for a few years and have been a consultant for some malpractice cases so the issue has more than a casual interest to me. The article cites a paper from NEJM that is a study of malpractice cases which is very enlightening.

To put it simply the problem which has created the "malpractice crisis" in the US isn't those nasty litigators, it is negligent doctoring. It seems that the vast majority of malpractice cases the doctor involved actually treated the patient in a negligent way. So the cure for the malpractice crisis is better doctoring which the Times op-ed piece suggests means evidence based practice.

Then again when one looks at how low chiropractic malpractice insurance costs one understands that such events are extremely rare in chiropractic. I think most people are shocked to find out how little chiropractors pay for malpractice, I know that every MD I have spoken to about the amount has envy. Most chiropractors pay a few thousand dollars for the same malpractice coverage that MDs pay tens to hundreds of thousand dollars in premiums.

SMP

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

Foundation for Anachronistic Chiropractic Pseudo-Religion

A friend recently sent me an email from the Foundation for Vertebral Subluxation (FVS). They say that they are: "Dedicated to the Founding Principles & Tenets of the Chiropractic Profession"

This is an attempt to revise the history of chiropractic to suggest that there was stagnate set of principles the some people today are trying to change. The founder of chiropractic, D.D. Palmer changed his theory about what chiropractic was three times over the seven years he wrote about chiropractic. (1) Some outside chiropractic like to point out that D.D. wasn't an M.D. or university educated. This is absolutely true, however, the evidence is clear that D.D. was well read and up-to-date when it comes to medical knowledge of his day. (2, 3)

If D.D. could change his theory three times then why on earth would the chiropractic profession want to pick one of D.D.'s or his son's theories and etch them in stone? That is dogma that has no place in modern health care or modern chiropractic.

The Dalai Lama was once asked what Tibetan Buddhism would do if it was shown conclusively that there is no reincarnation, a central tenet of Tibetan Buddhism. His response, "Tibetan Buddhism will have to change."

Given that D.D. was "in to" the literature, (3) I am comfortable with saying I am a loyal chiropractor and will not bow to one of those four theories of chiropractic D.D. had. Today's chiropractor has the duty to follow in DD's footsteps and rethink chiropractic as the science dictates. I know that some sell to their patients that they do chiropractic as it was done in the past and actually get some people to think that practicing chiropractic as they think it was practiced 50 or 100 years ago is better than making appropriate changes when the scientific evidence suggests that there is a better way.

I'm sure expressed this way, that most people would say, "gee do I really want to go to a chiropractor whose methods are from the early 20th century?" I think not. I mean who would go to any professional and say, "please do not be up-to-date"?

The Foundation for Vertebral Subluxation wants to preserve a term, subluxation, that D.D. didn't use until after the trial of Shegatoro Morikubo for practicing medicine, surgery and osteopathy without a license in LaCrosse WI.(4) Subluxation and innate intelligence were first used by Smith et al in the first textbook on chiropractic Modernized Chiropractic .(5)

Many in chiropractic never learned the origin of the pseudo-religion or chiropractic philosophy. (6, 7, 8). It was nothing more than a legal tactic used in Morikubo's case. After Tom Morris, Morikubo's attorney got the medicine and surgery charges dropped, the tactic was to say that chiropractic and osteopathy had different philosophies and therefore Morikubo wasn't practicing osteopathy. In some ways it is unfortunate, because this was successful and then BJ etched into stone "chiropractic philosophy". (4)

The late Dr. Joe Keating wrote two articles about Morris that are available on-line
Tom Morris, Defender of Chiropractic Part I & Part II

I love the photo below. it is of BJ Palmer's rehab facility at the Palmer School of Chiropractic c1945. (BJ's signature is on each of the rugs)

What this shows is that even BJ Palmer wasn't so pure and straight as he "mixed" using rehab. The FVS wants to live today in a chiropractic past that did not actually exist. Their revised chiropractic history is a pseudo-religion that has no place in today's chiropractic beyond a class in the history of the profession. It is about as relevant to dealing with the needs of today's patient as sulfa drugs and mercury are for the medical profession.

The subluxation is dead, long live chiropractic.

SMP

1. Keating JC, Jr., D.D. Palmer's Forgotten Theories of Chiropractic
   
2. Gaucher-Peslherbe P-L. Chiropractic: Early Concepts in their historical setting. Lombard, IL: National College of Chiropractic; 1993.
3. Gaucher-Peslherbe PL, Wiese G, Donahue J. Daniel David Palmer's medical library: the founder was "into the literature.". Chiropr Hist. 1995 Dec;15(2):63-9.
4. Keating JC, Jr. B.J. of Davenport: The early years of chiropractic. Davenport, IW: Association for the History of Chiropractic; 1997.
   
5. Smith OG, Langworthy SM, Paxson MC. Modernized chiropractic. Cedar Rapids, IA: Lawrence Press Co; 1906.
   
6. Keating JC, Jr., Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF. Subluxation: dogma or science? Chiropr Osteopat. 2005 Aug 10;13:17.
7. Mirtz TA. UNIVERSAL INTELLIGENCE: A Theological Entity in Conflict with Lutheran Theology. J Chiropr Humanit. 1999;9(1).
8. Mirtz TA. The question of theology for chiropractic: A theological study of chiropractic'sChiropr Humanit. 2001;10(1).
   
   
   

Bike Helmets

I can't remember how many times someone has sent me an email that is all about how we survived childhood without all the safety equipment that kids use today. The email goes on about concrete playgrounds, no seat belts no bike helmets etc. Yes it is true that we survived. But what about those who didn't from what now is a preventable cause of death.

Two days before I graduated from chiropractic college I turned my Honda Civic (they really tiny kind) into a Honda Accordion. I was distracted by a major collision, flashing lights everywhere, and plowed into a full size car at 50 MPH. If not for my seat belt I would surely have been ejected from the car and died. I was in a volunteer ambulance corps in high school and saw one of those where the car hit a telephone pole going much slower. Not pretty. I'm one of those who was "saved by the belt."

A few weeks ago, I was riding my bike to my office at the University of Bridgeport when a car made a right hand turn right in front of me. I hit a telephone pole with my head. But because of my children I barely was bruised. What do my kids have to do with my getting out of this relatively unharmed? I started wearing a bicycle helmet because they had to, plain and simple.

A recent study cited in the NYTimes found that states with helmet laws have far higher percentage of children who wear bike helmets. A big problem seems to be that for some the helmets are too expensive. Makes me wonder what's the problem with people who don't wear seat belts as all cars now have them. Cost can't be the reason.

I think the problem no matter what the safety device, is that people think, it won't happen to me. The odds are it won't but when it comes to bike helmets or seat belts the benefit far supersedes the costs in money or discomfort.

SMP

Surface deception - surface EMG

Although the article that stimulated this blog was published in February, I was only alerted to it by an automated Google news search, whose results that were emailed to me this week. The article is about the use of surface EMG to diagnose chiropractic subluxations. I won't go into the validity of the concept of the subluxation as I have co-authored a paper on that already, and the literature that supports or refutes our paper has not changed in any substantive way that I know of.

The article, sEMG: An overview, in my opinion, does little more than express, what I think, is a biased belief lacking any evidence that a subluxation can be demonstrated by sEMG. sEMG or surface EMG is a useful tool for certain purposes. One of those purposes doesn't happen to be diagnosis. It is really a research tool. Used to determine which muscle is active during certain movements. There are some sophisticated methods that are showing some promise in determining dysfunction that may be at the root of low back pain (1) or validating the diagnosis of low back pain. (2) but nothing I have seen suggesting that the sEMG can help find a subluxation. (3)

One fundamental problem with the use of sEMG to diagnose subluxations is that none of the methods used by my colleagues at this time involve what is called normalization. Normalization is where one converts the electricity measured during the sEMG to percent of maximum volitional movement or percent of some predetermined activity. The reason normalization is important is if one is just trying to compare the voltage from one patient to set of "normal" values inside the device one does not account for variables that change that voltage independent of muscle activity. For example, if one has an obese patient and thin one, the obese patient will have lower voltage readings on the EMG because fat is a great insulator without regard to the actual activity of the muscle. (4, 5) None of the sEMG devices that are marketed to chiropractors require normalization procedures before they produce their pretty computer graphics supposedly showing where the subluxation is.

Now most doctors of any profession lack the training that would provide them with the knowledge to evaluate the claims of the sEMG manufactures. However, if one reads the sEMG: An overview there are to simple clues to the lack of validity of these devices. The only references used are a twenty-two year old pilot study and a twenty year old book. Given the fact that approximately ten thousand papers are published weekly in the biomedical literature it is not that common that one needs to rely on such old references. Especially when professional groups both outside (6) and inside the chiropractic profession (7) have published since then noting the lack of validity of the use of these devices.(6, 7)

SMP

1. Cholewicki J, Silfies SP, Shah RA, Greene HS, Reeves NP, Alvi K, et al. Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine. 2005 Dec 1;30(23):2614-20.
2. Geisser ME, Ranavaya M, Haig AJ, Roth RS, Zucker R, Ambroz C, et al. A meta-analytic review of surface electromyography among persons with low back pain and normal, healthy controls. J Pain. 2005 Nov;6(11):711-26.
3. Owens EF, Jr. Chiropractic subluxation assessment: what the research tells us. J Can Chiropr Assn. 2002;46(2):215-20.
   
4. Lehman GJ, McGill SM. The importance of normalization in the interpretation of surface electromyography: a proof of principle. J Manipulative Physiol Ther. 1999;22(7):444-6.
5. Ng JK, Kippers V, Parnianpour M, Richardson CA. EMG activity normalization for trunk muscles in subjects with and without back pain. Med Sci Sports Exerc. 2002 Jul;34(7):1082-6.
6. Pullman SL, Goodin DS, Marquinez AI, Tabbal S, Rubin M. Clinical utility of surface EMG: report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology. 2000 Jul 25;55(2):171-7.
7. Position Statement of the American College of Chiropractic Consultants on sEMG 2006
   
   
   

The Weakening of Professionalism and the High Cost of Health Care 2

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.

SMP

Sick to debt

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.

Most of these people were in middle class jobs, owned their homes, were well educated and actually had health insurance. These aren't the kind of people one thinks of as getting in financial trouble due to medical bills. I mean most had health insurance. There clearly is something wrong with the system when someone with health insurance has to declare bankruptcy. I think most would have figured that the people in this financial bind were the so-called working poor. You know 3-4 part time jobs with no health insurance. Either way this is obscene. I know that some will say that it's not my problem but it is. The money that can't be paid back is absorbed by the overall economy. Thus each of us pays for this.

There ought to be a better way!

SMP

David U. Himmelstein, Deborah Thorne, Elizabeth Warren, Steffie Woolhandler, Medical Bankruptcy in the United States, 2007: Results of a National Study, The American Journal of Medicine, In Press,

The Weakening of Professionalism and the High Cost of Health Care

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.

This week's New Yorker has a great article about what drives up the cost of health care. The article by Atul Gawande, MD. Dr. Gawande compares the cost of health care in McAllen TX to nearby El Paso. The two areas have basically the same demographics and health statistics - so it's not the people. Yes El Paso's Medicare expenses are about half of McAllen's. McAllen has amongst the highest health care costs in the US. On the other hand Rochester, MN, home of the Mayo Clinic has one of the lowest.

I suggest reading the article but my take on this is very simple. The doctors at Mayo live up to the moral principle that created the social contract whereby society granted autonomy to professionals (classically health care, clergy and attorneys). Society created the social contract because it lacked the knowledge needed to properly understand and regulate the professions. The contract states that professions get the autonomy to practice as long as they subjugate the needs of the profession and professional to the needs of the patient, parishioner or client. The Latin phrase credat emptor replaces caveate emptor. The later, we all know means let the buyer beware. The former is let the buyer have faith. That is have faith that the recommendations that the professional makes are in the "buyer's" best interest not in the professional's.

Dr. Gawande's research shows that in McAllen and I suggest spreading around the US is an anti-professional ethic in health care to, as he writes, not leave money on the table. This means that one has made sure to bill for everything one can possibly bill for. I am a capitalist but I think this is a problem of values.

I've written in my ethics column in Dynamic Chiropractic about values. Below the lists of values from the Rokeach Value Survey. There are two types: Instrumental Values and Terminal Values. The former are those values that explain how we live our lives and the later are what we want out of life.

Instrumental Values

• Ambitious
• (Hard-working, aspiring)
• Broadminded (Open-minded)
• Capable (Competent, effective)
• Cheerful (Lighthearted, joyful)
• Clean (Neat, tidy)
• Courageous (Standing up for your beliefs)
• Forgiving (Willing to pardon others)
• Helpful (Working for the welfare of others)
• Honest (Sincere, truthful)
• Imaginative (Daring, creative)
• Independent (Self-reliant, self sufficient)
• Intellectual (Intelligent, reflective)
• Logical (Consistent, rational)
• Loving (Affectionate, tender)
• Obedient (Dutiful, respectful)
• Polite (Courteous, well-mannered)
• Responsible (Dependable, reliable)
• Self - controlled (Restrained, self discipline)
  

Terminal Values

• A world at Peace (free of war and conflict)
• Family Security (taking care of loved ones)
• Freedom (independence, free choice)
• Equality (brotherhood, equal opportunity for all)
• Self-respect (self esteem)
• Happiness (contentedness)
• Wisdom (a mature understanding of life
• National security (protection from attack)
• Salvation (saved, eternal life)
• True friendship (close companionship)
• A sense of accomplishment (a lasting contribution)
• Inner Harmony (freedom from inner conflict)
• A comfortable life (a prosperous life)
• Mature love (sexual and spiritual intimacy)
• A world of beauty (beauty of nature and the arts)
• Pleasure (an enjoyable leisurely life)
• Social recognition (respect, admiration)
• An exciting life (a stimulating active life)

I think that the cost of health care is due to the elevation of "A comfortable life (a prosperous life)" over "A sense of accomplishment (a lasting contribution)". This might be the rebound or backlash of the “60s”. I started practicing in NYC when Jerry Rubin (Chicago 7) hippie became a yuppie. There is a nice discussion of how he debated his co-conspirator Abbie Hoffman in the Wikipedia article on him under the subheading post activism. When I was in NYC in the early 80s I used to go to Jerry Rubin’s networking parties at the Palladium where business people went to meet other business people. I found it a waste of time. Nevertheless, life, it seems, had changed to profit mattered more than accomplishment.

Or to put it another way professionalism matters because until the prevailing ethic amongst all health care providers stops being the health of their personal wallet and it properly is the patient's health and value they receive from our care no effort will reduce cost with increases in health and wellness.

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

Ultracrepidarian Doctors and Back Pain

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.

There is a classic paper that sort of tested the prevalence of this disorder amongst very smart college students. The title says it all, "Unskilled and unaware of it: How difficulties in recognizing one's own incompetence lead to inflated self-assessments". (The link goes to free full text)

A new study, published in today's Spine by Buchbinder et al could be called ultracrepidarian doctors and back pain. The paper, "Doctors With a Special Interest in Back Pain Have Poorer Knowledge About How to Treat Back Pain" details a study that surveyed general practitioners about their interest and knowledge regarding how to treat back pain. The results are counter-intuitive because those with the greatest interest in treating back pain had the poorest knowledge of the current best evidence of how to treat it. Thus, they were ultracrepidarians.

It was almost comical but the doctors with a special interest in back pain thought that guidelines are very helpful in determining how to treat patients with back pain, yet they choose treatments, such as bed rest, that are clearly bad for patients. Bed rest in particular has been known to be harmful for a long time.

This paper is very similar to one published quite a while ago also showing that doctors choose treatments that are ineffective and avoid ones that are effective such as spinal manipulation.

Buchbinder and colleagues previously published studies that showed that public education reduces disability from workers compensation type claims. Sometimes the public is teachable and their doctors aren't. I wish I could give patients hope that the doctor they go to really is up-to-date but clearly if the doctor says they are does not mean that they actually are.

SMP

Resistance to using the best treatment

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.

This article talks about the Agency for Health Care Policy and Research's guidelines on treating lower back pain. (1) Spine surgeons were so upset that it excluded their favorite treatment - surgery - that they tried to kill the agency. As the Times article reports the reason that surgery was not recommended: research didn't show it was effective but it did show that spinal manipulation was effective.

But as Max Planck said: "A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it."

The problem is that people have a hard time changing. Most hate change. Personally I thrive on it. Most don't like finding out they were wrong. I used to be like that. I think the change was when I read the first study that suggested that spinal manipulation might be effective for treating some people's symptoms who have spinal stenosis (2)

This paper came out 2 years after I had told a patient who came in with CT showing the stenosis (he'd been symptomatic for ~10 years) that I couldn't help him and he should have the surgery he had scheduled. The study isn't what I'd call compelling evidence of clinical effectiveness of spinal manipulation but IF it had been published two years earlier I could have told this man he might have a 36% chance of getting better after two weeks of care. Given the fact he'd lived with the pain for 10 years he might have been willing to try two weeks of care instead of "going under the knife". For a while I beat myself up over this and then I realized, you can't know what isn't known. That liberated me to be comfortable with saying that was wrong. As W.V. Quine and J. S. Ullian wrote in The Web of Belief (Random House, New York, 2nd edition, 1978, p. 133) my favorite quote:

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.

SMP

1. Bigos S, Bowyer R, Braen R, et al. Acute Low Back Problems in Adults: Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health care Policy and Research, Public Health Service, U.S. Department of Health and Human Services; 1994.
2. Kirkaldy-Willis WH, Cassidy JD. Spinal manipulation in the treatment of low-back pain. Can Fam Phys. 1985;31:535-40.
   

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

Swine Flu & Chiropractic

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.

Let's look at the argument in favor of chiropractic as part of how ones family should "respond to the threat of the flu."

Supposedly Ronald W. Pero, Ph.D. performed one of the most important studies that showed the positive effect chiropractic care has on immune function and general health. First the link in the blog leads to an article about the 1917-8 flu epidemic. I'd like to see the original data rather than the owner of that web sites excerpts. Nevertheless it might be true that chiropractic care was better than medical care for the flu in 1917-8. There is a world of difference in the field of medicine between then and now. I hate to say it but I do not think there has been an equally large increase in the effectiveness of an adjustment. In fact I think most traditionalists in my profession would suggest it was as good as it was going to get way back when and we've only screwed stuff up since then.

I searched the National Library of Medicine's online database search system, PubMed to find any published paper by Dr. Pero on chiropractic. I can't find it. Here is that search. Here is another search of just what R Pero published. I read the title of all 183 papers and none appear to be about chiropractic. If anyone can find me the paper, rather than an article in a chiropractic newspaper talking about the research I really would be grateful to find the paper and read it.

Next the blogger discusses a study done at the National College of Chiropractic (now National Health Sciences University) by their then research director, Patricia Brennan. Brennan’s study, if anyone actually reads it, is not really about immune function. It was an attempt to find a physiological marker of active manipulation. The intent was to see if they could differentiate between a sham and real manipulation.

Lots of folks want to use this study to show how chiropractic improves immune function. What is stated: “phagocytic respiratory burst of polymorphonuclear neutrophils (PMN) and monocytes were enhanced in adults that had been adjusted by chiropractors.” is true. So to the true believer in the unlimited wonders of the adjustment this is “proof” that an adjustment improves immune function. Unfortunately, one cannot conclude this from that study. First of all the subjects were healthy normal individuals. We do not know if the response will happen to those who are ill. Maybe when one is ill the response is blunted or eliminated because the PMN’s are already “enhanced” by the need to fight an infection. Conversely, it is possible that the response is enhanced even to a greater degree in the person fighting an infection. We just do not know. Also the response was transient; it was found at 15 minutes but dissipated by 30 minutes after the manipulation. The true believer’s response would be, "so adjust the patient every 15 minutes." That seems logical, except we don’t know if the response is repeatable or if it fatigues. And again it could be more profound as it is repeated, we don’t know. Also we do not know if the increased phagocytic respiratory burst will actually work in any appreciable way to make one better able to defend against an infection or to help the individual get better faster or have reduced effects of the infection that one might have.

The blogger mentions a study done at Life Chiropractic University. There is no such educational institution in the US. The name of the institution is Life University which was Life Chiropractic College. For some reason there are a lot of people who make this mistake. If one googles "life chiropractic university" one finds many chiropractors web pages say they graduated from there. I suggest they take a look at their diplomas.

Regarding this study, I can not comment about any specifics, I haven't read the paper. My only comment is that good research requires replication and if the best we can do is a paper in a defunct journal that is more than 10 years old...

The blog goes on to say that chiropractic improves "And chiropractic care improves the function of the nerve [sic] system through improving the movement of the spinal bones that encase and protect the spinal cord." This is an interesting theory that has been espoused by some in my profession for years. I am aware of no valid research that supports this statement. 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. Overstating what we know only serves to decrease our credibility.

For information on prevention and treatment of influenza A(H1N1) (swine flu) see the CDC or CDC's flu pandemic web site or MedLine Plus (great consumer oriented health information). Hopefully your chiropractor will recommend these sources of information rather then suggesting that a sure-fire strategy is getting a chiropractic adjustment.

SMP