Issue 45 / 25 November 2013

WAS the response to MJA InSight’s recent chiropractic story “a turf battle in a sandbox” or are other principles at stake?

A fortnight ago our regular email newsletter arrived in your inbox with the subject line “Time to team up with chiropractors”. Admittedly, the phrase was composed for maximum “clickability” in the ongoing skirmish for your online attention on a Monday morning, but within minutes of sending we realised it had garnered considerably more interest than anticipated.

If you did click through you would have read our news story about the Chiropractic Observation and Analysis Study (COAST) study. COAST used similar methods to the BEACH (Bettering the Evaluation of Care and Health) study to document what chiropractors do in clinical practice.

Among 4464 chiropractor–patient encounters, some of the findings were that 60% of appointments were for musculoskeletal conditions, “maintenance and wellness” visits were frequent, the most common treatments were spinal manipulation and soft tissue therapy, treating infants aged under 1 year was uncommon, and there was very little cross-referral between chiropractors and GPs.

In response to questioning from MJA InSight, several experts agreed that GPs and chiropractors should communicate about patients under their care, and that chiropractors could be part of a patient’s primary care team if the treatment provided was evidence-based.

Not all of our readers supported these sentiments. In the hours after the newsletter went out we were told that “the MJA should be ashamed of itself lending credence to this pseudoscience”, that we were “submitting to political correctness” by publishing any information about chiropractors and that “GPs should continue to advise their patients that chiropractic treatment, unlike medical treatment, is unscientific and can be dangerous”.

The comments kept coming throughout the week. Chiropractors joined the fray, pointing to the shortcomings of the medical profession, the body of research supporting chiropractic practices and the general arrogance of doctors. Others took the opportunity to disassociate from some of their colleagues’ questionable activities — “please don’t lump all chiros into the same nut job basket! Support the professional evidence based, journal reading, thinking chiropractors!”

Our poll — “Should GPs refer patients with musculoskeletal conditions to chiropractors?” — kept pace. A week after the poll opened 503 votes had been cast, arguably InSight’s highest ever level of reader engagement.

Reflecting the polarised views of the comments, 37% of respondents agreed, 43% said no, and only 20% took the more moderate option of “Maybe — if evidence-based”.

Like one bemused commentator, we wondered about the “vitriol” in response to the story. Was it a case of (in the words of one chiropractor) “a turf battle in a sandbox” or were there other, more objective reasons for the longstanding tension between chiropractors and doctors?

There are some very important ways in which some high-profile, but not universal, chiropractic practices such as the ill defined concept of “subluxation” are at odds with evidence-based medical thinking. Media reports of some chiropractors’ active opposition to immunisation, use of spinal manipulation for infants and covert treatment of patients (including premature and critically ill babies) while they were in hospital under medical care have also done much to erode Australian doctors’ trust in chiropractors.

Concerns about these and other practices were reflected in readers’ comments. While individual chiropractors were able to provide examples of fruitful partnerships with GPs, it is not hard to understand why some doctors are reluctant to collaborate with a profession that tolerates such variations in practice within its ranks, especially when better evidenced and regulated resources, such as physiotherapy and musculoskeletal medicine, are available.

There are similar tensions in the US, where Dr Harriet Hall, associate editor of the Science-Based Medicine blog, recently lamented the failure of chiropractic to address the unscientific behaviour of some practitioners: “What if chiropractic had policed its own ranks, limited itself to providing only short-term treatment for certain types of musculoskeletal pain, worked hard to determine which manipulation techniques were most effective, abandoned techniques that it found ineffective, and denounced vaccine rejection, applied kinesiology, and other forms of quackery? … Chiropractors could have become ‘physical therapists for the back’, experts in manipulation that MDs could refer patients to with confidence. Chiropractic might have been integrated into the medical mainstream just like osteopathy and optometry, but it didn’t even try.”

The Chiropractic Board of Australia has this year made some moves to regulate its registrants’ approach to immunisation and paediatric care by producing two position statements. The board also announced a crackdown on chiropractors “who step outside their primary role as healthcare practitioners and provide treatment that puts the public at risk.”

These moves are encouraging, as is the advice of an academic chiropractor to his colleagues, in a 2011 paper on the future of chiropractic: “… it is time for the moderates and conservatives within our profession to become more involved with shaping its future … It is about time government, other health care providers and the public were made aware that not all chiropractors are pseudo religious zealots who have abandoned science for ideology”.

On one thing doctors and chiropractors agree — millions of Australians are “voting with their feet” to seek chiropractic care each year. Whether it’s teaming up or simply talking, it seems likely that patients will benefit from a bit more cooperation in the sandbox.

 

Dr Ruth Armstrong is the medical editor of MJA InSight.

14 thoughts on “Ruth Armstrong: Turf tussle

  1. Department of Health Victoria Clinicians Health Channel says:

    The accusations of lending credibility where it isn’t warranted were largely to do with MJA Insight giving the CAA CEO an uncritical free kick to put out spin which was unrelated to the article, and added nothing to the analysis of the COAST study. The Chiropractors Board has only made the right noises under severe duress from outside influences, and even then, it has not yet published any reports of discplinary action having been taken despite the much-applauded ‘crackdown’. Since when should a Board deserve credit for bringing wayward practitioners into line? Surely that’s its core business. Oh, and there’s no ‘turf war’. With around 4,500 registered chiropractors in the country, as opposed to 70,000 doctors and 250,000 nurses we won’t be driving taxis any time soon because of chiropractors taking our work. It’s about concerns over the quality of the advice chiropractoirs give, and the safety of their care in the face of ongoing denial by chiropractors to take responsibility for their adverse outcomes.

    As an observer of the chiropractic profession over several years, I don’t see their ability to unite around a moderate, evidence-based position getting any closer. The CAA, the largest professional organization, continues to actively promote pseudoscience and antivaccination propaganda in its CPD offerings, and denies that anyhone can be harmed by chiropractic care.

    The chiropractic profession will earn some respect when they choose to unite around a science-based, ethically defensible model of care that is not based on salesmanship and spurious claims. Words and media releases are not enough. Respect is earned, not demanded in this game. Until then, they deserve all the difficulties they bring upon themselves.

  2. dm robson says:

    “voting with their feet”!!!!  Numbers do not make a fact.

    For hundreds of years the earth was flat and the sun revolved around the earth.  For some in the US it still does!!!

  3. WH Huffam says:

    Apart from its doubtful scientific basis I have two big problems with chiropractic. (One) the physical danger of manipulation, I have had to perform an emergency laminectomy for a massive intervertebral disc lesion causing a complete cauda equina lesion immediately after a chiropractic manipulation.

    (Two) the cultivation of psychological dependency. As an orthopaedic surgeon has reached the age and stage of performing medicolegal examination I see many patients who continue regular passive chiropractic treatment for years with no demonstrable benefit .

  4. Department of Health Victoria Clinicians Health Channel says:

    The reality is that many Australians are simply unaware of the quakery that infects the chiropractic ranks. They’re “doctors” who have “degrees” and they have “practices” so they’re considered legitimate.

    Too much time or column inches are needed to explain why subluxations are ridiculous, paediatric chiropractic is dangerous, and anything outside of mild relief of back and neck pain is beyond their scope.

    The average Australian doesn’t have the ability to critically analyse these topics – and chrio has done a good job of instilling a “Sore back? See a Chiro!” mentality as beyond dispute.

    It would be simpler, cleaner, and more effective for evidence-based physicians to simply emphasise a ‘COCA=GOOD, CAA=BAD’ mentalitiy.

    It’s a simple thought process that patients will remember, at least. 

    When talking to patients with back pain, if they want to see a chiro, at the very least tell them to avoid the quacks with CAA membership, and encourage them to attend a COCA chiro.

    Sure, there’s some overlap in membership, but by-and-large, COCA chiros are at least a touch more responsible, discerning, and honest than the CAA mob.

    COCA=GOOD, CAA=BAD.

  5. John Quintner says:

    Without attempting to defend chiropractic practice, it is only fair to point out that Medicine has its own problems to overcome in the difficult areas of Musculoskeletal and Pain Medicine. One can readily point to important issues such as excessive opioid prescribing for spinal pain, endless “facet” joint injections, inappropriate spinal imaging, and needles spinal surgery, as examples where clinical practice has sometimes departed from, or even ignored, the evidence-base.

  6. John Cunningham says:

    “Millions of Australians” also believe in Santa Claus.  Doesn’t make him real.

  7. Patrick Hanrahan says:

    Millions of Australians have voted with their feet to endorse the smoking of cigarettes, excessive consumption of alcohol, driving at speed etc etc and the widespread adoption of Chiropractic can similarly not be taken as any endorsement of efficacy. The most effective treatment for back pain is natural history and all treatments, to some extent, rely on this. As a rheumatologist many of my patients see chiropractors and I accept it because that is just the way it is, and I read the letters provided by their chiropractors with interest, but I really don’t see that I have to collaborate with them any more than I need to communicate with the naturopaths and iridologists that my patients see. I don’t agree with chiropractic care for a number of reasons. I find it disturbing and a sign of partisanship that the medical editor should belittle this debate with reference to turf wars, sand boxes and an evidence free suggestion that patients would benefit from more cooperation. Australian GPs are the backbone of our very good health care system and they need support as the apex of care, rather than as just one of myriad competitors on a level playing field (or sand box!)

  8. Adrian Sheridan says:

    It took me years to earn the trust of doctors and develop a medical referal base. Doctors don’t refer lightly. When you refer do you write physio or neuro or ortho or chiro, or do you specify a practitioner?  It is all about TRUST! If I promoted any BS with the doctors patients they would cut me off instantly. It is also about good communication between the Dr and chiro.

    The chiropractic profession also needs to develop a culture of self examination, evaluation and criticism which is already strong in medicine. Until then Dr’s like Mick Vagg are very important. Change is good and necessary, even if it is under duress.

    P.S. I am a member of COCA!

  9. Department of Health Victoria Clinicians Health Channel says:

    Somewhat skeptical, at least there is plausibility and ongoing evaluation of the effectiveness of these treatments. Just because airplanes crash if they are not properly flown and maintained, there is no reason to think magic carpets would do a better job. The answer to the problems of medicine is not chiropractic.

  10. Ashlea Broomfield says:

    I agree with paddy. ” Australian GPs are the backbone of our very good health care system and they need support as the apex of care, rather than as just one of myriad competitors on a level playing field (or sand box!)”

    unfortunately the moves from the government and private insurers to validate some professions as primary carers has undermined the role of the GP as the coordinator of care and gatekeeper for medical services. Not only are GPs seen as comparators, the government now wants to further allow non medical professionals to prescribe…

    No wonder we have difficulty attracting people to General Practice. 

  11. Chris Strakosch says:

    Speaking of practice without scientific basis which is believed my many- how about an article on the benefits of prayer? That should break your inbox record. 

  12. Edward Brentnall says:

    We have well trained scientifically based Physiotherapists for the treatment of musculo-skeletal problems and soft tissue injuries.  Why would medicos refer these conditions to any pseudo-scienfitic “Health Professionals”?  Until we have a rational basis for sending patiens to Chiropractors we should avoid them like the plague!  EB

  13. John Quintner says:

    Could Mick Vagg let readers know how he thinks the problems of Medicine as outlined above are going to be solved?

    Paddy Hanrahan appears not to appreciate that there are chiropractors who may well have more knowledge and expertise in the management of people with spinal pain than some of his rheumatological colleagues. 

  14. Richard Shiell says:

    It is 50 years next November since I graduated MB.,BS from Melbourne University.  Since that time men have walked on the moon and sent probes to the far reaches of the Solar System but the same old disputes about the value of chiropractic treatment contine unabated.

    What I have learned in half a century is that many people find chiroctactic treatment helpful.  I have also come to appreciate the role that time and rest play in body healing. Furthermore there is the undeliable ” placebo effect ” of  well meaning treatment from a respected medical adviser of any pursuasion.

    I predict that this debate will continue for another 50 years.

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