Issue 43 / 11 November 2013

CHIROPRACTORS and GPs should bridge their professional schism and take a team approach to treating their patients to optimise treatment, according to experts.

A study published online today by the MJA on the clinical practices of chiropractors found chiropractors referred patients to a GP in only 3% of consultations and patients had been referred to a chiropractor by a GP in 4% of consultations. (1)

The Chiropractic Observation and Analysis Study (COAST), based on chiropractors in Victoria, was the first of its kind in the world.

Data collected between 2010 and 2012 on 4464 chiropractor–patient encounters from 52 chiropractors showed 60% of appointments were for musculoskeletal conditions, mostly for back problems.

The research showed patients were commonly treated for “maintenance and wellness” or check-ups, which constituted 39 of every 100 chiropractor-patient encounters. The most common treatments were spinal manipulation and soft tissue therapy.

Most (71%) encounters involved patients aged 25–64 years while 1% of encounters were with infants aged under 1 year.

Professor Marc Cohen, of the School of Health Sciences at RMIT University, said the lack of cross-referrals and communication between GPs and chiropractors identified in the research represented a professional schism that few practitioners seemed willing to cross.

“This schism may also indicate that patients are compartmentalising their treatment plans and not discussing their treatments with their different practitioners”, he said. “This may lead to suboptimal care and reduce the effectiveness of the therapeutic relationship.”

Professor Cohen said a lack of understanding across the many different health disciplines, along with real or perceived competition between them, hindered interdisciplinary communication.

He said patients were likely to benefit from a coordinated care approach where they felt free to discuss all their treatments with their practitioners, and their treating practitioners collaborated to provide the safest and most appropriate care.

Professor Peter Brooks, director of the Australian Health Workforce Institute at the University of Melbourne and chair of the Australian Acute Musculoskeletal Pain Guidelines Group, said chiropractors should be part of the primary care team but all members of the team should espouse and practise evidence-based care.

“At least an exchange of information between [GPs and chiropractors] would assist treatment and diagnosis”, he said.

The study authors said most people who saw a chiropractor and other complementary and alternative practitioners also consulted a medical practitioner. They suggested further research “to maximise the patient benefit that can be gained through a team approach to primary care”.

Dr Liz Marles, president of the Royal Australian College of General Practitioners, said it was important for GPs to know if their patients were receiving chiropractic treatment to ensure treatment plans were not conflicting.

“It is of utmost importance that chiropractors keep GPs informed and report back on any findings and treatment plans”, she said.

Andrew McNamara, CEO of the Chiropractors’ Association of Australia, said his organisation encouraged chiropractors to refer to a GP when it was in the best interests of the patient.

“Patients with musculoskeletal conditions will benefit from managed or integrative care, particularly where the patient wants a drug-free approach or wants to consider all options before surgery.”

Professor Cohen, who is past president of the Australian Integrative Medicine Association, said the snapshot of chiropractic practice provided by the study was useful to GPs.

“Knowing that many of their patients are seeing chiropractors may prompt GPs to open discussions about chiropractic care and communicate with chiropractors about reinforcing evidence-based lifestyle recommendations”, he said.

Professor Brooks said it was a good thing that chiropractors were mostly confining their work to musculoskeletal problems.

“Mind you, a lot of back pain will get better whatever we do”, he said.

Professors Brooks and Cohen said further research was needed to determine the patient outcomes from chiropractic services.

The MJA research authors said it was important to have reliable, up-to-date information about what is actually happening in chiropractic clinical practice, with about 4400 registered chiropractors practising in Australia.

 

1. MJA 2013; Online 11 November


Poll

Should GPs refer patients with musculoskeletal conditions to chiropractors?
  • No (43%, 216 Votes)
  • Yes (37%, 188 Votes)
  • Maybe - if evidence-based (20%, 99 Votes)

Total Voters: 503

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77 thoughts on “Chiropractors–GPs told to team up

  1. Ray Taylor says:

    How can we possibly “team up” with a group whose basic doctrine is that all disease is caused by misalignment of the vertebrae? Surely that would be lending credence to this weird philosophy…

  2. Department of Health Victoria Clinicians Health Channel says:

    What kind of advice is this? A completely science-free discipline being given additional legitimacy? WIll GPs be referring newborn babies for manipulative therapy as well now?

  3. Department of Health Victoria Clinicians Health Channel says:

    Surely as doctors we should be referring patients for therapies for which there is a reasonable evidence base and that we have confidence in… not sure whether chiropractic treatment fits the description…

  4. Cindy Mak says:

    I am a surgeon who believed once that chiropractors were all quacks. But now, as a regular patient, I look forward to my visits and feel my chiropractor has a significantly better understanding of anatomy of the back than I do. I get her to explain her manipulations to me, and they make sense.

  5. Ian Hargreaves says:

    During my orthopaedic training I assisted my boss at the spinal unit to reduce a C5-6 unifacet dislocation. Despite general anaesthesia with muscle relaxant, image intensifier control, a patient with known acutely torn ligaments, and over 200 kg of orthopod hanging off his head; it was very difficult to manoeuvre the spine by 5 mm.

     

    My eminent spinal surgeon boss mused wanly on how the chiropractors managed to manipulate the spine under less favourable circumstances.

     

    Perhaps for ‘evidence-based’ care the GP could MRI the patient before and after the manipulation, to see how far the vertebrae have moved.

  6. Michael Gliksman says:

    And astronomers, don’t forget to hook up with astrologers.

  7. Peter Aquilina says:

    This is beyond belief!

    why on earth would a science based/evidence based profession refer to a group of quacks who believe that correction of a non-existence entity (“subluxation”) can cure all manner of illness. What’s more, a significant cohort of this “profession” actively advocate against vaccination and fluoridation. It will be a cold day in hell when I refer a patient to a chiropractor. The MJA should be ashamed of itself lending credence to this psuedoscience. I look forward to the next article recommending referal and collaboration with homeopaths, irididologists and clairvoyants.

  8. Leo Hartley says:

    Chiropractors do not believe that all disease is caused by misalignment of the spine. This sort of disinformation only increases the gap between the professions. Regardless of what GPs say, people keep returning to chiropractors for back care because it works for them!

    I am a medical practitioner and have found that chiropractic works best for me when I have acute lower back pain. This is despite the fact that my health fund does not reimburse for chiropractic care. While large, double masked, multi-center, RCTs would certainly help chiropractic’s cause (there’s no drug company to fund them), I don’t need to see this sort of evidence to know that chiropractic works for me.

    It’s not that long ago that optometrists and podiatrists were vilified by the medical profession just as chiropractors are presently. Now, GPs routinely refer diabetic patients to optometrists and podiatrists. Medicine clearly does not have all the answers, so patients will continue to seek what works for them despite medicine’s claim that chiropractic isn’t evidence-based. Remember, much of what medicine did years ago (blood letting, purgitives and emetic treatments) were nothing short of barbaric by todays standards.The name of one of the medical professions most prestigious journals, “The Lancet” bears tribute to medicines’ days of blood letting for all manner of illness. 

    Chiropractic care doesn’t deserve the bad reputation that organised medicine promotes. Certainly, more evidence for it’s efficacy would help chiropractic, but to vilify a profession the way that organised medicine does is unprofessional at least and smacks of turf grabbing at worst.

  9. rod ryan says:

    I just have one legal question – if I referred a child for spinal manipulation and their spine was broken (as happened recently in Australia), or they died (as happened recently in the Netherlands), could I be held partly legally liable, and would my Medical Defence Organisation still defend me even though I had  referred someone for an intervention which was not scientifically proved?

    http://anaximperator.wordpress.com/2009/05/07/infant-dies-after-craniosacral-therapy/

  10. George Spyropoulos says:

    Do not give any more legitimacy to chiropractors

  11. Andrew Crawford says:

    MJA appears to have given great assistance to the Chiropractic Board of Australia’s efforts to expand Chiropractors Scope of Practice to include prescription of S4 and S8 medications.  The Chiropractic Board can do this unilaterally, without reference to any external body except to call for submissions ( and then disregard all medical submissions as being tainted by turf protection and self interest).  There is no appeal process except on procedural grounds, AHPRA cannot intervene on any other grounds.  This has been the case with optometrists awarding themselves the right to diagnose and treat glaucoma and will surely be same for psychologists to prescribe for depression, chiropractors to prescribe for diabetes, and so on.  The AHPRA legislation has opened the way for major changes to the practice of medicine.  The AMA should be explaining this new landscape to all doctors and patients, lound and clear, so that all can decide if this is really the way that medical treatment ought to go. 

  12. Wendy Wilkinson says:

    I do not understand the advice in this article.  Referring patients to chiropractors for musculo-skeletal lower back pain may be considered, but physiotherapists also treat this within an actual evidenced based modality. 

    In addition to further legitimising chiropractors that subscribe to the magical chiropractic subluxation as the cause of of most conditions of ill-health, and also given that these chiropractors are anti-vaccination, where is the ethics in referral?  Chiropracty also noteably has NO adverse event system, and as we have seen recently will go out of the way to ensure that chiropractic professionals are not at fault when injury occurs. Again, how can patients be referred to such a treament modality?

    The ‘schism’ has nothing to do with GPs making more effort to understand and be inclusive and everything to do with chiropracty, in the reliance on the pseudoscience of subluxations being a primary care ‘wellness’ modality,  not being evidence based for anything other than musculo-skeletal back pain.  

  13. nat Sheehan says:

    I don’t refer patients to priests, homeopaths, or iridologists either. Stop cluttering up this journal with crap.

  14. University of Queensland - Central Library says:

    Why on earth would I refer to a chiropracter with no evidence to back their practice, when I could refer to a physiotherapist?

    I agree that it’s important to know what treatment plans patients are undertaking, however to suggest that doctors should actively support the chiropractic profession is ridiculous. This article seems to have forgotten the importance of evidence based medicine.

  15. Department of Health Victoria Clinicians Health Channel says:

    The post by “Medical Practitioner” deserves a further comment. Fortunately this is not 1765 and hopefully we have moved on a little since then. The fact that blood letting was part of primitive evidence-free medicine does not justify a similar approach in 2013. In an era of whole exome screening, this is really a laughable argument and contains so many logical fallacies that there is little to be gained by detailing them. This is not an attack by “organised medicine”, rather a desire to promote the scientific method that we now value to inform medical practice rather than empiricism and quackery.

  16. Department of Health Victoria Clinicians Health Channel says:

    This is a small study of very questionable generalizability (authors claim 52 chiros completed it, but if you read the text, only 33 fulfilled all the criteria for completion). It describes the practice patterns of a small group of chiros who appear to treat mostly back pain, though there are some other slightly concerning diagnoses being treated. It was funded by CAA and the Victorian Chiropractic Board (ie by the industry being studied) and seems to have been used as a platform for the CAA to launch another PR campaign to distract from the diastrous year they have had. It’s disappointing to see that even worthwhile (if hardly impressive) research is being co-opted into propaganda.

  17. Geoffrey Miller says:

    When I qualified as a medical practitioner in 1954 , I was taught that I could be struck off the Medical Register if I associated with an unqualified practitioner such as a chiropractor.  When did this change?

  18. dm robson says:

    There is enough navel-gazing and anti science without the AMA submitting to political correctness and  validate the un-validateable.

  19. Thinus van Rensburg says:

    The problem with the publication of such a small and questionable study is that the Mainstream Media will pick it up and run with it. The whole world will now be told that the “most powerfull Union in Australia” aka the AMA (as  the anti-doctor crowd often refers to the AMA) is advising us to refer people to these quacks. These “Integrative medicine” advocates, e.g. ex President Phelps and people like Marc Cohen, are a danger to our profession and we should stop pandering to the PC crowd and call a spade a spade. I do not refer to Chiros, Naturopaths or other quacks as they have no legitimacy in an evidence based medical approach.

  20. Department of Health Victoria Clinicians Health Channel says:

    I suspect the main reason that chiropractors don’t refer to doctors is because most chiropractors call themselves “doctor” anyway.

  21. John Cunningham says:

    Dear Surgeon,

    I taught anatomy to chiropractors at Uni, and I’ve never met one who had a better understanding of anatomy than myself.  Many of their observations are correct, but then they overlay a functional and pathological layer on top that makes little sense.  If you feel better for it, then good on you, but if they claim they are treating anything other than back pain, then I’d be sugegsting you look a little deeper into what you, and they, understand by “subluxation”.

    Because no one has yet been able to define or image a chiropractic subluxation.

    No one.

    Regards,

    Mr John Cunningham

  22. Matthew Yap says:

    Such vitriol in response to this article. For GPs to acknowledge that many of their patients are also visiting chiropractors allows for a discussion on what (useful or harmful) advice and therapies the patient is also using alongside those prescribed by medical practitioners. The schism perpetrated by comments such as above only widens the lack of communication, and GPs remain ignorant of their patients’ full history. Open communcation about what chiropractors are doing with their patients may help to improve evidence-based practice all round.

    This was a small study, and I wonder about its representiveness of the Australian chiropractor – more studies into alternative treatments would be very beneficial for our profession to understand the context in which we work. The article above does not recommend anywhere that GPs refer to chiropractors.

  23. The University of Melbourne says:

    In response to Medical Practioner who stated “While large, double masked, multi-center, RCTs would certainly help chiropractic’s cause (there’s no drug company to fund them), I don’t need to see this sort of evidence to know that chiropractic works for me.” A quick search of PubMed shows 391 clinical trials of Chiropractic in humans, but 18,563 for physiotherapy. Physiotherapy has worked hard to produce a body of evidence to inform their practice. In response to the claim “know that chiropractic works for me” – of course, but does it work better than a massage, or physiotherapy and what are the risks associated with chiropractic manipulation compared with massage or physiotherapy? Chiropractic does not carry out clinical trials, nor does it has a system for recording adverse events. A 5 year undergrad degree only supplemented with 25 h/year of CPD means that chiropractors are extremely less qualified than other medical professionals. These are a few of the reasons for concerns about a number of chiropractic practices and a possible reason for low numbers of GP referrals

  24. George Skowronski says:

    I’m delighted that only 3% of GPs are prepared to refer patients to chiropractors, the vast bulk of whose practice is unsupported by scientific evidence, as evidenced by the 39% of patients treated for “wellness” and the apalling 1% of infants treated.

    I’m disappointed that a physician of the eminence of Peter Brooks would suggest that chiropractors should be part of the primary health care team.

    In my view GPs should continue to advise their patients that chiropractic treatment, unlike medical treatment, is unscientific and can be dangerous. The fact that substantial numbers of our patients believe in ‘alternative medicine’ is not a good reason for us to embrace it.

  25. Hall Patrick Apte says:

    I have only twice in my been ‘treated’ by a chiropractor.  Once on the recommendation of a colleague and once by one in Los Angeles who was referred to as Doctor (Name forgotten) when I called the desk of the hotel I was staying in and awoke with  severe lower back pain.

    The “Doctor”duly arrived and on hearing my accent declared that he was: “Doctor (Name forgotten)…doctor to the Stars and Australians”.  He was over six foot tall and told me to stand back to back with him and put up my hands so that he could hold them. I did and he grabbed my hands and immediately bent forward as fast and as far as he could. I cried out with the pain. He then dropped me to the floor and told me to go to a drug store and buy a brace to wear and that I would be OK now and would have no pain in a few days.

    Guess what,  it did not work for me, but back in Sydney a week later a physiotherapist did…and that was directed by my GP.  Please do not confuse chiropractic with real practicing Medical Doctors.

  26. Sue Ieraci says:

    It would have been interesting for the survey to ask whether GPs collaborate with physiotherapists – I would not have been surprised to find a result of close to 100%. Those who do refer to chiros would only refer, I suspect, to those evidence-based chiros who treat musculoskeletal issues – which is the only evidence-based area of Chiro. Until recently, I did not realise how widespread the ”subluxation” and ”innate intelligence of the body to heal” approaches were. Search the first ten chiro websites you find – almost certainly they will take this type of approach. Many, many chiros also believe that the birth process creates a newborn’s first ”subluxations” which need correction throughout life, to maintain ”wellness”. It seems that, although chiros do train in some version of the clinical sciences, they diverge early to a ”philosophical” approach of ”dis-ease” (sic), and really only conduct clinical examination for ”subluxations” and posture – there is very little direct clinical training. Meanwhile, the few frustrated evdience-based chiros seem to sit on the fringe. Ultimately, the question is this: do we need two manipulative therapy professions, one based on science and one on philosophy? Certainly GPs should inquire if their patients are being treated by other providers, but REFER patients to them? Unless the chiro is helping with musculoskeletal back pain, or perhaps sports injuries, what would be the purpose of preferring them over a physiotherapist, who is already part of the therapeutic team?

  27. GEORGE QUITTNER says:

    WOULD YOU LIKE TO HEAR A FAIRY STORY? :

    A big strong healthy patient went to a chiropractor for a “check up” and the chiropractor said: “Go away.  There is nothing wrong with you” !

  28. Dr Bob Thomas says:

    I agree with most comments above.

    Should we forget that the CEO of one of Australia’s largest Chiropractic Organisations is actively supporting the anti-immunisation campaign in this country ? Also, should we forget the numerous CVAs caused by vertebral artery thromboses following manipulation? The list is endless!

    No …………Give me a properly trained musculo-skeletal physician or physio any day!

    I place most chiropractics only just above the rest of the “snake-oil” merchants seeking some form of quasi-professional recognition — aroma therapists, homeopaths, iridologists, reflexologists etc.

    “Good” chiropractics may have a small place in “manipulative medicine” & vet. medicine — possibly.

    Chiropractics NEVER receive referrals from me — how do I know if they are “good” or even “well trained”  ??

    The Chiropractic Board was so pathetis that it felt that an “internal manupulation of the hip” was Okay when a female patient charged one such chiropracter for “bodily invasion” some years ago! The chiropractor was exhonerated…………….So much for their ethical standards.

  29. Adrian says:

    There is a lot of baggage attached to the word Chiropractor. This does tend to attract a knee jerk response, but ultimately this response is the fault of the chiropractic profession itself, who communicate poorly with doctors. Health is the ultimate team sport and for subluxation based chiropractors to think that they can practice in “glorious isolation” as a “one stop fix all shop” is delusional. I have been in practice for over 20 years and all the doctors in the area know me. Initially I got a lot of anti-referrals, that changed to quiet tolerance and then with regular reports and communication I got referrals. The initial patients were horror backs that had tried everything else and I think it was a case of OK smartarse you want it, try this! I then started to get referrals from doctors I had never had any communication with, but they knew me through feedback from their patients. Ultimately, this led to an invitation to join some doctors in practice. I now happily work in a medical centre. This has been a revelation. Some patients take their doctors for granted and behave dreadfully. If one of my patients did this they would miss the sidewalk, they land on the road. Doctors put up with a lot of crap and stress!

    I often get asked “What is the difference between you and physio’s, osteo’s, massage, etc? My response is “everyone is approaching backs with a different technique and no one approach helps everyone, just like your doctor will vary your medication and dosage to achieve the best result. You need to find which approach works for you. If I cannot help you I will refer you to a good physio, doctor etc”. Dr’s don’t refer lightly as it reflects back on them! Trust must be EARNED!

     

  30. J Love says:

    Nothing like a turf battle in a sandbox; why would any md evidence-based treated patient not be totally cured? or feel any need to visit a DC? 

  31. John Cunningham says:

    J Love, Are you the very same chiropractor who boasts about going into Emergency Departments to adjust your patients?  Allow me to remind you by clicking here.

    If so, your comment about a turf war is truly superb, given that you’re the one quite literally stepping onto medical doctors’ turf!

    Maybe you should think twice before leaving pithy fallacious comments like you have done here.  Why would anyone ever expect to be “totally cured”?  Are you expecting to live forever?

  32. Adrian says:

    It is not a turf war, as chiro’s only see approx 8% of the population. Who ultimately sees 100%? If a Dr refers to me and I do a good job the patient is happy with the Dr, If I stuff up the patient is unhappy with the Dr, Not me! Dr’s don’t refer lightly as it comes straight back at them. The Dr’s referal network is their bread and butter and getting added to their referral network is difficult. Conversely, the Dr will cut you off at the knees in an instant, so it is a relationship that must be worked on constantly. I always think of my refering Dr’s as being like a High Maintenance Blond girlfriend! Trust is everything! Its not up to the Dr’s to chase the chiro.

    Some chiro’s should stop playing the victim and start acting professionally. Chiropractors that are doing this already should be supported by their medical collegues. This will develop a momentum for change, where the subluxation chiro’s drop the “S” word and come onboard or get left behind. COCA is already there with cooperation, collaboration and communication. This is what the article is saying. Please don’t lump all chiro’s into the same nut job basket! Support the professional evidence based, journal reading, thinking chiropractors!

  33. Michael Black says:

    The Evidence is there, it is just hard to find. Most of the evidence is recent – last 5 years.

    Further work is required however:

    Spinal high-velocity low amplitude manipulation in acute nonspecific low back pain: a double-blinded randomized controlled trial in comparison with diclofenac and placebo.

    http://www.ncbi.nlm.nih.gov/pubmed/23026869

    Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?

    http://www.ncbi.nlm.nih.gov/pubmed/21245790

    The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain.

    http://www.ncbi.nlm.nih.gov/pubmed/20889389

    Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation.

    http://www.ncbi.nlm.nih.gov/pubmed/22483611

    Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: results of a pragmatic randomized comparative effectiveness study.

    http://www.ncbi.nlm.nih.gov/pubmed/23060056

     

  34. Colin Brice says:

    As I chiropractor I work reasonably hard to keep up to date with recent research regularly exceeding the CPD requirements for the profession. I am saddened by the apparent lack of up-to-date commenters. There is a mountain of research linking nerological benefit of normal range of motion with nearly all aspects of health from digestion to emotional control to falls risk. There is good research also showing SMT has little benefit and has great benefit (mostly on back pain but more coming through on neck pain and sports perfomance). There is evidence that GP and Physio care actually makes back pain outcomes worse and some that shows it improves outcomes.

    I suggest that any practitioner that refuses to acknowledge that patients/clients are individual and may get better results from a different profession have there head firmly buried in their doctrine. One of my regular pieces of advice to my clients is that if their practitioner suggest that they know everything and they don’t need to go anywhere else then GET ANOTHER PRACTITIONER. Health is far to encompassing for one practitioner to know everything!

    In my practice I refer to GP, Orthopod (via GP), Physio, Myotherapist, Councellor, Acupunsturist, Naturopath, and Dietician off the top of my head. I find I rarely refer to a different chiro… go figure… must look into that 🙂

    To all the folk with their head in the doctrine no matter what your profession, I hope you stand up and look around soon! There are much better ways to assist your patients than we had in the past and improved outcomes is the main objective right?

  35. chrisw says:

    If you refer or recommend a patient to see a chiropractor and they thereby obtain a Medicare rebate for it, and if the chiropractor decides to treat or manage something completely unrelated, eg. bowel symptoms or asthma, they  will still claim a Medicare rebate for it even if you do not approve. And if the patient suffers injury or omits proper medical treatment because of the chiropractor’s actions, you are LIABLE.

    How can any doctor that believes in science support a false belief or deception? If you support it, you must be able to explain to your patients what a chriopractor believes, and why that treatment works. It is NOT the same as an optometrist or physiotherapist whose practice is based on science.

    You CANNOT and MUST NOT refer to someone or recommend someone when you cannot explain and justify before a court of law or to your peers why you recommended the patient see a chiropractor.

    For the same reason, if the university or the government cannot explain the basis of chiropractor treatment and why and how the treatment works, DO NOT SUPPORT IT. DO NOT FUND IT. DO NOT TEACH IT. We do not want to regress to the “dark ages” of quackery and deception.

    All the doctors that have seen chiropractors or other people that have seen chiropractors for any illness, have you ever thought WHY and HOW the treatment works? Was the back pain going to improve anyway? Was it because there was massage? Was it just a PLACEBO EFFECT? Do not argue that your chiropractor has been successful in treating you unless you can EXPLAIN WHY AND HOW IT WORKS. You should know better!!!!!.arci

     

     

     

     

     

     

     

     

     

     

  36. Yvonne Day says:

    As a patient I would change my GP if she dared to refer me to a chiropractor.  I prefer to be treated by a physiotherapist if necessary and even then will question manipulations that I am not comfortable with.  I have friends that are continually going to their chiropractor without getting more than a few hours relief.  Not for me.

  37. Anna Frecker says:

    I prefer the physiotherapists approach, both diagnostic, evidence based, and giving me exercises which will reduce my dependence of physiotherapy and help to reduce my need for them in the future.

    I ask my patients who go to chiropracters what exercises they’ve  been given to help fix the problem and I don’t think any of them have said that their chiropracters have. So they may help people but I think physiotherepists approach is much more ethical.

  38. Dr Sue McCoy says:

    It’s bad enough that now medical practitioners have to suffer the insult of being included under the same registration umbrella as osteopaths and chiropractors with the creation of the mega-bureaucracy known as AHPRA. I lament the passing of evidence-based practice but as a wise and learned friend (previous dean of a large and prestigious English medical school) once said to me – ‘a community gets the medical profession it deserves’. Lump us together with phonies and quacks and eventually that may be what we morph into. I shall be retired before then – I hope.

  39. Michael Black says:

    There is Evidence Based Research that has come out recently regarding the differences between Chiropractors and Physiotherapists of which I have both in our Practice.

    They work well together for the patients benefit. However they are different in techniques utilized:

    J Occup Environ Med. 2011 Apr;53(4):396-404.

    Health maintenance care in work-related low back pain and its association with disability recurrence.

    http://www.ncbi.nlm.nih.gov/pubmed/21407100

     

     

  40. William says:

    Classic John Cunningham,No-one in the world could possibly know more anatomy than John.  Pretty sure Nik Bogduk might give him a lesson in spinal anatomy.  Guess he should should stick to evidence-based medicine and prescribe some thalidomide, vioxx, diclofenac and statins.   The arguements against chiropractic care are so antiquated with nay-sayers continuing to use decades old definitions and theories to suggest that it chiropractic is quackery.  Subluxation is a term to describe joint dysfunction.  No longer does it refer to a bone out of place like the surgeon and John like to push.  Much like the continued used of the term arrythmia which is out-dated and inaccurate.  John wants to see it on imaging to believe it.  There are many concepts in science that are accepted without being able to see it. 

  41. William says:

    Ian Hargraeve, John Cunningham.  Chiropractors don’t push bones in that have moved out of place. Are you reading a chiropractic text from 1910? I  have a medical text from 1935 which suggests treating a sore throat with a rectal injection of warm soapy water. Should I use that text to form an opinion? Is it not plausible that a joint may demonstrate abnormal motion following sustained poor posture, trauma, degeneration or other abnormal load?  As a result of the abnormal motion at the joint, it is not plausible that this could result in some local pain?  Where there is pain at the joint, is it not plausible that putting a high velocity force into that joint might elicit a stretch reflex, fire the golgi tendons in the muscle spindle?  Can pain modulation result from direct inhibition of the anterolateral system though mechanoreceptor stimulation of interneurons in lamina II and V thereby synapsing with other nociceptive afferent axons?  Would that not release met-enkephalins thereby inhibiting nociception presynaptically?  I wonder if there could be any result from spino-thalamic activiation releasing endorphins?  I wonder if such stimulation of those afferents, the periductal grey matter and nucleus raphe magnus could excite interneurons through the descending serotonergic pathways to cause post-synaptic inhibition of the preganglionic sympathetic neurones of lamina VII thereby restoring vasomotor control?  Could that sympathic inhibition reduce nociceptor stimulation and decrease substance P release?  John wants to see a nerve that connects from one place to another.  Maybe he just needs to better understand neurophysiology. What would I know, I’m just a quack!

  42. Robyn Rutherford says:

    Many GPs are renowned for prescribing medication for everything –  No questions asked.  Many Chiros are known for overservicing.  Many Physios are renowned for ‘not touching & just putting machines on me’.  Seriously?  Do we need to automatically degrade other professions?   For all those people quick to write derogatory comments please keep in mind that not all Chiropractors work the same.  As a Chiropractor myself (that is a little disillusioned with the profession in general – for this reason), I receive many referrals form GPs who have themselves been to see me as well and know how I work.  They are the first to refer appropriate cases.  I am married to a Physiotherapist.  We cross refer clients all the time.  We each understand our limits and where our expertise lies.  Does that make me a bad person because I’m a Chiropractor?  I dont think so!  People are missing the big picture of this whole article.  “CHIROPRACTORS and GPs should bridge their professional schism and take a team approach to treating their patients to optimise treatment, according to experts.”  Your comments are just proving why this article has been written.  And for the record… I refer my clients to GPs probably about 30-40% of the time, for lots of reasons (often not necessarily for the reason they have seen me in the first place).  Two opinions are better than one aren’t they?  It’s sad to see ‘the health care industry’ as a whole not caring about patients individually. Lets start caring for patients rather than our own EGOS & our own WALLETS.  And lets get our facts 100% right before we make accusations please – we are all grown ups!

  43. Sue Ieraci says:

    I used to think that rational CHiros were like “Thinking_Chiro” – essentially working on musculoskeletal and sports injuries. It appears from the public presentation of chiropractic – not just through websites and the social media, but through some of their representative organisations and adademics – that this is not the case. Belief in The Subluxation, the Innate ability of the body to heal and non-spinal health being caused by nerve interference is concerningly widespread. I have also found that what exists in the body of research for chiro is mostly limited to case reports (especially of single cases) and surveys, and related to mostly self-limiting conditions. There is reasonable evidence about chiro for musculoskeletal back pain. Rational chiros also seem to contribute to something like fitness coaching or sports medicine.  Unfortunately, ”Saddened Chiro” has a misunderstanding of the quality of evidence – especially in paediatrics. I have read a lot of the current work that is produced by leading chiro academics and researchers – most of it is very poor quality, anecdotal and uncontrolled descriptive work. “saddened chiro” should be more saddened by the state of evidence in his/her own profession than in comments from other professions. There is no ”turf war” – most doctors have more than enough work, and don’t do musculoskeletal work themselves anyway – they refer to physios. The chiro profession can only gain wider respect from health care colleagues when evidence is produced that its methods are both plausible and effective, when claims of effectiveness are limited to this evidence, and when there is an evidence-based scope of practice. The Subluxation belongs to history.

  44. James Lehman, DC, MBA, FACO says:

    The National Prevention Strategy for the United States of America calls for collaboration of all health care providers including chiropractors and the coordination of primary care.  The University of Bridgeport College of Chiropractic provides chiropractic services within primary care facilities (Community Health Center, Inc.) for the evaluation and management of patients suffering with chronic pain. (Lehman J and Anderson D.  Health Care Reform: Primary Care Teams in ACOs. ACAnews. April 2013.  Available from: http://www.acatoday.org/content_css.cfm?CID=5137.) The chiropractors have been integrated successfully as medical staff members.  To date, patients, administration, and primary care providers are pleased to work with the chiropractors.  A study published in 1999 demonstrated that chiropractors and medical doctors can work side-by-side.  (Pasternak DP, Lehman JJ, Smith HL, Piland NF. Can medicine and chiropractic practice side-by-side? Implications for healthcare delivery. Hosp Top 1999;77:8-17.) 

    For the benefit of patients, health care providers should collaborate and coordinate care.  I suggest that interested medical doctors attempt to work with chiropractors that are patient-centered and evidence-based providers.

  45. Philip Clarke says:

    Oh goody, I get to share homeopathy and iridology recipies with the local chiros. What’s next, RACGP mandates activators (sticks that go click – very impressive!!!!!) for doctors bags????

  46. R foster says:

    I know many people that have chronic back pain, tried the GP , the physio and sometimes the chiro. It often gets better. Would that have happened anyway? Irrespective the person that has helped them through is valued and valuable.

    in my opinion the concern is chiropractors who think they are qualified to be primary care physicians- priding themselves on managing viral illness without antibiotics and discouraging ‘dangerous’ vaccinations. This practice has the potential for great harm- to herd immunity and the most vulnerable in our society. 

    The low referral rate of chiropractors to GPs suggests the 40% of non musculoskeletal patients they are seeing are either very well (and probably don’t need to see anyone) or the chiro is grossly overestimating their magical powers to cure disease with healing hands alone! 

    It is also a bit unethical to choose self limiting conditions (eg infant colic) to treat weekly at great expense until tincture of time has worked it’s magic. Whilst I avknowledge there may be an element of emotional support for the patient or  parents can we really justify the cost?

  47. Simon Locke says:

    What is a musculoskeletal condition?  Are chiropractors trained in assessment of tendon injuries,  rehabilitation, soft tissue injury or back pain?  Should terms be clarified before questions asked?  The question re MSK conditions  covers tendon, ligament, joint, cartilage, synovium etc.  Are all GIT problems simply ” abdominal conditions”?  Questions like that do not add to any debate.

  48. Geoffrey Harding says:

    There is an organisation called the Australian Association of Musculoskeletal Medicine which has been in existence for over 40 years which has been running courses for medical practitioners in the evidence-based assessment and treatment of musculoskeletal pain problems (most of which is acute and chronic low back pain). This evidence-based (non-surgical) approach has been shown in a number of trials to be more effective than usual care and reduces patient dependancy on therapists. It reduces the cost of care and scores highly in patient satisfaction. The assessment methods and treatment approaches are based on solid medical knowledge and research as taught by such medical luminaries as Prof  Nik Bogduk, Prof John Murtagh, Assoc Prof Michael Yelland, and Prof Norm Broadhurst (three of whom have been Presidents of the Association). Why would the medical profession need to “team up” with the chiropractors before “teaming up” with the knowledge base and skills of fellow medical practitioners who have always been there to teach their knowledge to fellow medicos.? Why default to Chiropractic (with all of its alternative paradigms) as the only method for dealing with musculoskeletal pain problems. I’d be happy to provide an outline to the MJA of the whole curriculum in Musculoskeletal Medicine so that it could highlight what is already inside medicine.                                                Dr Geoff Harding, Immediate Past-President, Australian Association of Musculoskeletal Medicine.

  49. GEORGE QUITTNER says:

    there is another ELEPHANT IN THE CHIROPRACTIC ROOM and that is X RAYS.  Nobody seems to have mentioned the ten gerzillion unnecessary irradiations ordered by these enthusiasts.  Just as the medical profession has discovered 99% of the back X rays we used to order were a waste of time. The emperor has new clothes and chiropractors “see” X ray pathology which is invisible to highly trained radiologists.  While I am on a role, would somebody please explain to chiropractors that houses are built square.  Healthy humans and trees are not.  Most people are not “out of alignment”…and even if they were…a manipulation will not “put them back”

    I love youze all.

    GQ

  50. David Mills says:

    AF – I went to see a chiropractor last week. Having done some manipulation that greatly relieved the discomfort I was experiencing she gave me an A4 sheet of exercises. She demonstrated and explained the ones I needed to do daily. On the other hand I’ve seen the work of surgeons who I wouldn’t let carve my roast chicken, I’ve seen GP’s I wouldn’t recommend to another living soul and physio’s who barely gave me the time of day. I wouldn’t use my experience to make generalisations about the medical profession. I’m very grateful there are so many outstanding practioners around. As with chiropractors, it’s finding the good ones.

  51. Adrian says:

    The article says “GP’s and Chiro’s told to team up”. This cannot happen unless there is communication and Trust between the individual practitioners. This takes time to develop. Any communication must use a common language that both parties understand. The chiropractic use of the term Subluxation and the medical meaning are totally different. CAA Chiro above used neurology to explain what he is doing. Well done! You are talking in terms that Dr’s understand.

    Change will only come from the ground up, not from above down. Any chiro reading this TALK TO YOUR GP’s.

  52. Brett moore says:

    Just in on ninemsn http://news.ninemsn.com.au/world/2013/11/12/10/26/german-court-jails-photo-snapping-medico. A gynaecologist who secretly took intimate photos of more than 1000 patients in Germany has been sentenced to three and a half years in prison.

    Do we therefore paint all gynaecologists with the same brush?

    There is good and bad in every walk of life. Chiropractors have far less complaints made against them (per 1000 practitioners) than GP’s, physio’s , psychologists etc. They also have a very high satisfaction rating.

    Chiropractors make lots of people feel better, what else matters?

  53. Dr Thomas Baster says:

    I would like to echo the comments by Dr Geoff Harding about a group of medical practitioners with a special interest in managing patient’s with acute and chronic spinal pain. Most are general practitioners and belong to the Australian Association of Musculoskeletal Medicine (http://www.musmed.com/) The focus is on evidence based medicine/procedures and referring doctors can be assured that patients  are given the real benefit of this approach in diagnosis and management. Patients may choose to go to Chiropractors, Osteopaths, Physiotherapists, Massage Therapists, Myotherapists etc but as a profession the focus should remain on directing them in an evidence based way. The effect of chiropractic has consistently been shown to be slight or modest at best. (Spine J. 2011 Jul;11(7):585-98. Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial. Bronfort G, Maiers MJ, Evans RL, et al)

  54. Sam Liveriadis says:

    Dear medical “evidence based practitioners”. I have been practicing Chiropractic for over 27 years helping hundreds of patients every week. Many my patients come in disappointed and unhappy from  your “scientific treatment”   Take this pill, oh it didn’t work why don’t you try that one now and if this doesn’t work let’s cut it out. If you were all that scientific and evidence based as you want to be believed you are Chiropractic would have long disappeared. Drug companies funding “scientific research”?…Please do not insult people’s intelligence ! Do you think people are ignorant, with no judgment  or ability to decide for themselves what is best for them?. You still live in the 50s when you were thought as the authority in health. Let me inform you, that era has long gone. Human bodies are much more than just bags of chemicals that can be measured or modified up or down. Your evidence based treatments miss this point all together. If you had all the answers  along with your physiotherapy subordinates, there would have been no room for us. The majority of my patients have tried  all your “scientific evidence based treatments”  before they come to seek my help. I am hounered by their trust in asking me for help, a lot of times, in defiance to the negative nonsense as their Dr tries to scare them off Chiropractic. 27 years now I can think of the great number of people from the youngest (yes I do treat children) to the oldest, that because of chiropractic, stopped taking harmful drugs and especially those that were saved from surgery. At the end of the day we do not need your referral or cooperation or approval.  People vote with their feet and that’s what matters.

  55. Sue Ieraci says:

    CAA CHiropraqctor does indeed talk neurological language – but does this make him/her evidence-based? Chiro training does include a lot of clinical science at the outset, but then diverges significantly into spinal manipulation practice, with very little other clinical teaching. Like the pre-technological thinkers, chiro seems to be stuck in the phase of theroetical model which is applied and sometimes seems to work – but the theoretical model remains untested. Medicine has moved beyond the ”humours” and other ”logical” models to ones based on direct measurement. We can measure action potential duration, intracellular calcium flux. We can image through EM, MRI, u/sound. It is no longer ”we believe it is valid, and we think it works ” – the methods exist to test the mechanisms – or disprove them. As it stands, chiro research is very basic, consisting almost entirely of  case reports or small series. There is almost no basic science research and very little clinical research. Althought there is a  research foundation for chiro in Aus, they use only a small % of revenue to conduct research. I have no doubt that ”thinking chiro” and others are sincere and well-motivated. There is a long gap, however, between good motivation and thoughtfulness vs providing care  based on plausible scientific mechanisms, and tested against placebo  for clinical effect. Of course medicine isn;t 100% evidence-based, but it covers an enormous scope and is the fall-back system for all-comers, in all states of severiity and all types of illness and injury. Everyone knows good chiros and bad doctors – but it is the very underlying principles of practice that are also crucial – not just individuals.

  56. Larry says:

    I am amazed by so many of the above comments. A lot of the ridiculous commentary above borders on moronic. My education in N America was at top institutions, and it amazes me that some of you hold yourself so high above other professionals who you know nothing about, and merely judge by your inbread prejudices, that are largely just over exagerated lies and myths. I have been practicing over 18 years and the amount of disgraceful, unprofessional and low standards of patient care that I have witnessed within your own profession outweighs any that I have seen within my own or any other. You are all so quick to judge, but as time evolves it is becoming so obvious that the propaganda and the lies and personal attacks you perpetrate aren’t working, the public is waking up to the facade that is medical “health” care. That is an oxymoron. You are good at emergency care, that’s it. END OF SENTENCE. The rest is just jibber jabber that when you spin it a certain way and tell it long enough…you all start to believe it. Seriously…beside the drug rep coming in once a month and giving you a 15 minute workshop on the new drugs available…what else is there? Evidence Based Care…start in your own back yard. There is a list so long it’s a joke. You want research, there is so much research on mechanical mobilisation of the spine and extremities it’s ridiculous. The majority of you call yourselves educated, I bet half of you couldn’t do an orthopedic exam. How many people die from surgery? Here is an article about flu shot data from Canada http://www.cbc.ca/touch/health/story1.1127442 interesting who is doing the manipulating of information to the public, how many people died from viox? oxycontin…how long do we go. CLEAN UP YOUR OWN BACKYARD

  57. Harvey says:

    I have a question. When my patients come in and they have already been run through the medical / physio mill…a few times, with no result and maybe worse, should I refer them back to the GP? You must understand that 90% of my patients come in AFTER they have already been to 3 or 4 GP’s, specialists, physios etc with no benefit from the EBC that you speak of. Interestingly though, I have clients that I have seen since birth that are now bringing their own children in to see me. Must be my “snake-oil” sales techniques. Thanks but NO thanks.

  58. Toni Hamilton says:

    As a chiropractor I have over many years of practice written to GPs hundreds of times.

    I have not once had a reply.

    Perhaps we should look at the communication gap from both sides.

     

  59. Sue Ieraci says:

    Readers who have not been exposed to the size and nature of the chiropractic literature might be confused by Larry Livingstone’s comment ” there is so much research on mechanical mobilisation of the spine and extremities it’s ridiculous.” Unfortunately, the body of literature on either the basic mechanisms or the clinical effectiveness of chiropractic is scant in comparison to either medical specialty areas or physiotherapy. As we saw in the ”neuroscience-ese” discussion above, there is a lot of speculation about mechanisms that are not supported by evidence. Manipulative therapy for low back pain IS evidence-based. No doubt manipulative therapy benefits people with musculoskeletal problems, done effectively and appropriately. On the other hand, I’ve lost count of how many chiros promote the ”adjustment” of children, for problems allegedly initiated either in utero or during birth. This is a completely evidence-free zone. It may not be practised by rational chiros, but the ”adjustment” of babies and small children is clearly very common in the chiropractic community. No amount of bluster about medication side-effects will make this type of chiro practice more valid.

  60. Michael Busby says:

    As an ENT surgeon, I’m interested to hear a chiropractor’s perspective on the following:

    What exactly does a chiropractor do to treat asthma, sinusitis, sudden sensorineural deafness, otitis media, reflux etc and what are the mechanisms by which that helps?

    What exactly is a subluxation (the chiropractic type – because previous commentors suggested that it had a different meaning to what doctors refer to as a subluxation) and how does it cause disease? 

    What are you looking for when you order X-Rays? Do they change your management?

    How does manipulation work as a preventative / wellness / maintenance measure in someone who is healthy?

    If you pull apart a “clicker machine” does it have anything in it other than something that goes click when it moves at high velocity but low amplitude?

    Is it really just a minority of chiropractors that are anti-vaccination and manipulating babies’ necks, and practising “functional neurology” or is that a fairly mainstream approach?

    Many of my patients are under the impression that chiropractors go to the same medical schools as medical doctors. Many naturopaths also use the title “Doctor” in their advertising. Do you think that the title “Doctor” is being overused to make some practices seem more credible?

     

     

  61. Adrian says:

    I was curious about whether someone has actually done research and made a thorough comparison betwen all the different treatments for back pain. This was done by the North American Spine Society in 2008 in a special issue of “The Spine Journal”. The 25 most popular treatments each had an article done by the leaders in that field. The results were then tabulated http://www.ncbi.nlm.nih.gov/pubmed/?term=Evidence-informed+management+of+chronic+low+back+pain+with

    There is over 270plus pages. One article tabulates all the results and discusses them. It is the best – http://www.ncbi.nlm.nih.gov/pubmed/18164475. Enjoy. The results will surprise you! The author is Dr Scott Haldeman-Chiro,PhD,MD,Neurologist,Prolific researcher and author. I think he knows what he is talking about. In reply to M BUSBY: The first question in regards to reflux, otitis media etc there is only case studies and low level research. Subluxation was a term invented over 100 years ago to differentiate chiro’s from Dr’s  so they would not be jailed for practicing medicine without a licence. Legal smoke and mirrors that got set in concrete. Should have been tossed long ago. X-rays are used only if there is a valid clinical reason in my practice. Example – trauma, chronic or unresponsive to treatment, red flags, etc. The patients often present with a large pile going back years. We see OA,RA,congenital abnormalities,cervical ribs,congenital fusions, facet trophism etc. They change the management. I also see approx 2 spinal metastasis/year.

     

     

  62. Adrian says:

    Further to M BUSBY queries. The Clicker/Activator is actually a spring loaded surgical mallet used by dentists many years ago to remove teeth. Horrible thought. Chiro’s took the chizel off and put a rubber tip on it. It can deliver a force of 1-25lb (Adjustable). So more than just a sound!

    Now how does manipulation work on a healthy patient? If you mean symptom free, then as a good friend who is a cardiologist once said “The worse symptom is no symptoms”.  I am constantly educating patients on school backpacks, lifting, sitting ergonomics, good beds, exercise etc. I prescribe lots of rehab exercises.  If I can help prevent problems developing and keep someone healthy, active and mobile then I am doing my job. Better than waiting for the patient to crawl in with excruciating pain.

    OK the biggie, Antivaccination Chiro’s. 130 in the AVN out 4700. They are an embarrassment. My children and I are vaccinated. If you believe in health and prevention then nothing in medicine encapsulates that more profoundly than Vaccination.

    OK now the other elephant in the room, the title Dr. I do not use it, as it creates confusion in the eyes of the public. When we had state registration boards, if you used the title you were diciplined and fined, especially in NSW. When we all went to AHPRA they gave us the title, but only if used “doctor of chiropractic”.  The whole thing should be stopped. Write a letter to AHPRA, I have. AHPRA seems to be driving everyone nuts! Not just Chiro’s.

    Last but not least, Functional neurology. The course is run by the Carrick Institute (USA) and is run over two years and extremely difficult and thorough. If you have any inquiries talk to Paul Noone PhD in Victoria, he teaches it.

  63. William says:

    To Dr Busby, I thank you for your questions. SIncerely appreciated. Before I cover those topics, I just want to say that we can ask the same question of many widely accepted medical practices.  For example, I read recently from Michael Vagg that we still don’t understand the mechanism by which paracetamol acts, but there are good logical theories and rationale for its action. Countless other examples may be put. As for Asthma, sinusitis, etc, I am not a chiropractic neurologist and it is far from my personal area of expertise.  I believe there is a good understanding of the sympathetic inhibitory pathways which may impact cortisol and other inflammatory mediators.  Even just affecting the sympathetics altering vasodilation may explain why people with sinus pain respond to adjustments quickly.  It is most important to ensure that the patient with asthma is co-managed with the GP and no-one would seek to take an asthmatic off their meds as it is not our role.  If there is any indication of acute respiratory distress then these patients are sent to A&E and not adjusted with magical intent.  Non-infectious sinusitis and  otitis media often demonstrate immediate observable positive effects with upper neck manipulation.  Though one should not be confused with pygogenic casues of the disease in which antibiotics or antifungals should be appropraitely prescribed.

  64. William says:

    Subluxation is an interesting one.  Medics term it as a loss of joint congruency to a lesser degree than dislocation.  OK, so at what point of joint juxtaposition is it no longer a subluxation? What if there is subtle joint disrelationship, not visualised on x-ray? Could this still result in a joint motion dysfunction?  I think this could still be classified as a subluxation from a joint dysfunction mechanical perspective.  Can you see it on x-ray, no.  What you can see on x-ray is gross changes in biomechanics, including changes to normal joint coupling on function views.  Lets forget the mechanical theory of subluxation as it was coined over 100 years ago when we actually thought bones moved out of place and had to be put back in.  Now the research into subluxation theory concerns the neuropathophysiological, kinesiopathological, biochemical, and histological effects of abnormal joint motion and the effects of a high velocity manipulation of a joint.  This neurophysiology of manipulation is far more important to understand and the profession has wonderful researchers analysing this.  Personally, I’m not sure that we need to even identify a joint motion abnormality through phys ex or imaging.  If we can better understand the neurophys of a manipulation, it doesn’t matter how the joint is moving because if you whack it, the effect will result.  I urge you not to get caught up on terms of reference which have no impact on the cause and effect of a manipulation.

  65. Sue Ieraci says:

    ”CAA Chiropractor”’s comments are interesting in light of what I have read in chiro ”functional neurology” and neurophysiological research. WIthout wishing to personally criticise any well-motivated chiro, the fact is that both of these theroetical areas are poorly developed and even more poorly researched. The recent CAA National Development Forum was addressed by Randy Beck – one of the most prominent US chiro neurologists. YOu can read his presentation here: http://nationaldevelopmentforum.com.au/images/stories/files/session3-beck-chiropractic-treatment-approaches-to-neurological-dysfunction.pdf. You will see that many of the conceptual models and clinical signs are highly dubious. One of the ”wonderful researchers” working on chiro neurophysiology is NZ Heidi Haavik PhD, head of research at the NZ College of Chiro. Here is a link to one of her recent papers: http://www.sciencedirect.com/science/article/pii/S0161475410003611. The methodological issues are clear – even acknowledged by the authors. Again, without meaning to personally criticise individual chiros, the body of research in chiro is very basic, poorly developed, and consists mostly of case reports. The basic science research is very scanty and controlled clinical trials of adequate size are almost non-existent.  This is the reality, no matter how well-motivated individual providers are.

  66. George says:

    Dear Editor

    Please do not publish such article to legitmise the quackery of chiropractise which is supported by RMIT . It is disgusting that 10 million dollars of tax payermoney is spent on Chiropractor sevices to patients .

    Can not under stand how a GP could refer patient to Chiropractor when evidence based medicine services are provided by physiotherapist

  67. Mia says:

    I always thought that the “innate intelligence of the body to heal” is nothing else but a reference to homeostasis, and it made/makes perfect sense. The ‘concept’ of the homeostatic mechanism and it’s role in health and disease is NOT alien to conventional medicine, is it?!All I see – as reflected in the comments – is hysteria and knee-jerk reactions. Yes, I could also point out that a minisucle number of medical interventions are actually EVIEDENCE-BASED. It is more like CONSENSUS-BASED. It apears, ‘friend of science’ are more like ‘freinds of the consensus ….based on what?’. The horror – with which the medical profession seems to recoil at the thought of coming in contact (germs?) with any chiro is comical.        For those too inevested in protecting thier turf, I would recommend reading the blog set up by Dr Skeptic: “This blog explores the true effectiveness of medical interventions, established through scientific study, as opposed to the perceived effectiveness. This highlights our overestimation of the benefits and underestimation of the harms from these interventions.” http://doctorskeptic.blogspot.com.au   Hope this will help you highlight some of biases you fail to acknowledge and own up to.

     

  68. University of Adelaide says:

    Friends of Science in Medicine (http://www.sciencinmedicine.org.au) applauds communication between those caring for patients and supports evidence-based practice of any kind. However, the COAST study did not uncover, and had very few responses from, chiropractors treating non-musculo-skeletal complaints and those who are treating babies and children for a wide variety of illnesses including infections, colic, failure to thrive etc. The low response rate in this Victorian survey may have omitted non-responders unwilling to declare more extreme practices.  The medical profession is wise not to support non-evidence based alternative practitioners. In referring patients to them, or in forming partnerships with them, they become potentially liable for these unproven practices and any adverse outcomes. The potential benefits of chiropractic for musculo-skeletal complains should be discoverable by quality randomised control trials. Then the benefits, side-effects and costs of any proven modalities can be considered by practitioners and their patients. To date, the quality of the evidence is weak. Other more controversial treatments, such as  the primary care of sick children or neurological disorders, might have difficulty in receiving ethical approval  to test in proper trials their therapeutic claims.  Untestable is untenable. “

     

  69. Adrian Sheridan says:

    Friends of Science in Medicine makes a good point for evidence. My previous post shown below covers that well. FSM will be surprised by the similar levels of evidence to chiropractic across the board for the 25 most common appraoches to the treatment of chronic LBP. See the North American Spine Society 2008 special issue of “The Spine Journal” which published the 25 most popular treatments by the leaders in that field http://www.ncbi.nlm.nih.gov/pubmed/?term=Evidence-informed+management+of+chronic+low+back+pain+with

    Chiropractic also needs quality RCT’s. I think one of the core issues is that medicine has a culture of looking at critically and reassesing what they do, chiropractic does not and it is overdue.

    I have a good referral relationship with my local doctors and we communicate constantly. They do hold me accountable and would cut me off at the knees instantly if I promoted any rubbish with their patients. It took me years to earn their trust.

    In response to Mia2 – This is not a turf war as chiro’s only see 8% of the population. Who ultimately sees 100%? Chiro’s should stop playing the victim and start looking critically at what we do! Critical evaluation, reassessment and research lead to PROGRESS. Maintaining the status quo is Stagnation!

     

  70. Sue Ieraci says:

    “Thinking Chiro” expresses the attitude of a professional that many of us would be happy to collaborate with  – for patients with low back pain of musculoskeletal origin, or musculoskeletal injury. The issues remain that a large percentage of chiros do not think or operate like this, and that the scope of practice of chiro is far from limited to the areas supported by evidence. I have not done a formal survey of chiropractors, but I have looked at many many public websites and facebook pages of chiropractic practices, and found an abundance of people ready to claim that newborns need adjustment soon after birth (for purported invisible birth trauma), and that chiropractic influences the course of labour and childbirth, ”strengthens the immune system” and is essential for overall ”wellness”. Many chiros run their practices as a combination of fitness coaches and motivational speakers. Perahps it is time for a split – evidence-based musculoskeletal chiros to side with physios and the rest of the registered health professions, others to remain in the ”wellness” industry but be held accountable for false advertising.

  71. Adrian Sheridan says:

    In reply to Sue Ieraci: The original article above saying GP’s and Chiro’s should team up won’t happen from above. It happens at the coal face with chiro’s communication with GP’s and earning their trust. So the division between different chiro’s in regards to their doctors has already happened. My GP’s and specialists know exactly how I practice. As for dodgy websites, it has happened to me. I had my site set up by a company that specialises in chiro’s and I found that Subluxation was throughout all their templates, so I rewrote a lot of it. I would be surprised if many chiro’s critically audit their sites regularly. I once had a doctor tell me he finds the anti Dr literature in our waiting rooms annoying. I said I don’t have any, but I critically went back and read the lot and immediately threw out over 50%. Learn and progress and accept any criticism and move forward.

  72. University of Queensland - Central Library says:

    Quite disapointed to see such inconsiderate responses from some medical practitioners.

    Any objection to chiropractic on the basis of lack of evidence is complete nonsense.

    Crikey, in general practice there is a lot of unscientific stuff that we use for good reasons.

    Anyone who thinks that there is an evidence base for much of medical practice is delusional.

    I have heard plenty of flagrantly unscientific stuff from many of my medical and physio colleagues.

    So what is the problem with seeing a chiropracter if it is safe and it works ?

    Obviously there is always a proportion of people who push the boundaries in any profession, but if you know and trust a chiro then there should be no problem in referring to that individual.

    Years ago that was the basis of most GP referrals – you refer your patients to someone that you trust, be they a Surgeon, a Physio, or a Chiropracter.

     

     

  73. Michael Miller says:

    ant-paternalistic convert, You talk about an infant in Australia with a broken neck from a chiropractor then link to a Norwegian story about a cranio-sacral therapist.  1. The story in Australia has been debunked and the “pediatrician” that made the diagnosis still refuses to accept the evidence that it was not a fracture but a congenatal anomoly. (guess he isn’t interest in “evidence” or “best-practice”. http://www.theaustralian.com.au/news/nation/chiropractor-cleared-over-break/story-e6frg6nf-1226740575036

    2. in case you’re interested “cranio-sacral therapists” and Chiropractors are not the same. 
    As to “evidence based” there are volumes of evidence as to the safety and efficatiousness of Chirorpactic but in my experience talking to most GP’s they are too busy seeing patients, prescribing meds and arranging surgical referals to read their own journals let alone dig in and do research on Chiropractic.
    I gladly supply them with journal articles from such prestigious publications as Spine, Clinical Journal of Pain, Sports Medicine, JAMA, NEMJ, Lancet and others to show them how to provide better care and end up with more satisfied patients.

     

  74. Louis Adams says:

    Right, so the chiropracter performed a cervical spine manipulation on a baby with a congenital spondylolysis, how is this acceptable? It is further evdence that chiropracters should not be treating children. 

    As to the volumes of evidence you speak of, judging by the names of the journals you have referenced, I assume you are talking about chiropractic and the treatment of low back pain, which I think I, and most others on here would agree, the evidence supports this. It is the treatment of children, and disorders other than musculoskeletal ones, based on the concepts of functional neurology, that we disagree with. There is no evidence that supports these areas of chiropractic. 

    And yes, how appaling it must seem that GPs are to busy seeing patients.

  75. Sue Ieraci says:

    “Patient patient” – the discussion about the chiropractic model and practice is not just about whether manipulative therapy can assist with muscular problems (it can) but whether the widespread model for ”subluxation” being the cause of ”nerve interference”, and causing a variety of dysfuction, even in newborn babies, holds any validity. Sure some doctors and physios are better than others, but medical practice is built on evidence of how the body works – through physiology and pathology, and clinical trials. Many good chiropractors can help you with muscular pain and spasm. When they claim to be able to treat other forms of ”dis-ease”, based on the experiments of the founder of Chiro who claims to have restored hearing to a deaf person, something needs to be done. Despite frequent claims that these are ”fringe” practitioners and that most chiros are rational and evidence-based, I have seen lots to show me that this is not true – there is a substantial group of chiros who promote the subluxation model and treat babies and children – lots and lots of them.

  76. Adrian Sheridan says:

    In response to Sue Ieraci:

    I think that in any discussion on chiropractic, there is the problem that the Subluxation true believers are all you hear as they love shouting, or as Jennifer Barham-Floreani in a recent podcast said “The loudest voice wins!” Reasonable chiro’s are quietly doing the right thing and communication with their local doctors and don’t have time for arguing with the BS merchants. I recently discussed this issue with a collegue about getting through to them and he just rolled his eyes and said “they won’t listen”. Institutional change has occured at COCA and needs to happen at CAA/ASRF. Support the good chiro’s and continue to apply the pressure to the Woo Meisters. Just don’t throw a net over the lot of us!

  77. Sue Ieraci says:

    Point taken, Thinking Chiro, but your profession needs to be sorted out from within. Criticism from the medical profession generally only serves to entrench the zealots and incur accusations of vested interests. COCA needs to coordinate rational chiros in a campaign to hold the rest of the profession to task, and to encourage the CBA to regulate effectively.  Just the fact that so many chiros post anonymously says something in itself, don’t you think?

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