Happy Haloween, everyone!

I just had the pleasure of seeing about 800 children walk past my office this morning on the yearly Haloween Walk, sponsored by our business association.

Besides goodies for the kids, we have handouts for all the moms about the benefits of chiropractic.

And that always makes me think about the dangerous side-effects of medicine, also known as iatrogenesis or iatrogenic injury.

Many of these poor little children have been given unnecessary antibiotics.

I hope you will find both these information pages as useful resources in advising your patients who have children.

 Thanks to Dynamic Chiropractic for permission to reproduce this article!

By Deborah Pate, DC, DACBR

A few years ago,  I wrote an article (May 22, 2006 issue of Dynamic Chiropractic) reviewing vertebroplasty as a treatment option for painful compression fractures due to osteoporosis.  [1] I felt that as chiropractors, we should be aware of the common medical procedures that are available to treat disorders we generally manage; osteoporotic compression fractures being one such entity.

From the information available at the time, vertebroplasty was considered a reasonable treatment option for painful osteoporotic vertebral compression fractures.

A recent article in the the New England Journal of Medicine has changed my impression of vertebroplasty. The article reported on a multicenter clinical trial evaluating the efficacy of percutaneous vertebroplasty for the treatment of painful osteoporotic vertebral compression fractures. [2] In the study, patients who had one to three painful osteoporotic vertebral compression fractures were randomly assigned to undergo either vertebroplasty or a simulated procedure without cement (the control group). Participants could have up to two spinal levels treated.

Participants were enrolled in the study for one year and were evaluated at entry and at one month and 12 months; and with phone calls at days one, two, three and 14, and months three and six. After month one, crossover from the placebo group to the vertebroplasty group was allowed.

Continue reading …

In two previous articles, here and here, I talked about author Simon Singh’s battle with the British Chiropractic Association. The Guardian reported yesterday that the initial ruling has been overturned.
From The Guardian:

A science writer who is being sued for libel by the British Chiropractic Association is to fight on after a preliminary judgment against him was overturned on appeal today.

Simon Singh was sued by the BCA after he wrote an article in the Guardian criticising the association for supporting members who claim that chiropractic treatments – which involve manipulation of the spine – can treat children’s colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying.

Singh described the treatments, for which he said there is not a lot of evidence, as “bogus” and criticised the BCA for “happily promoting” them.

In May, Mr Justice Eady in the high court ruled on the meaning of the words, saying they implied the association was being deliberately dishonest. Singh said that interpretation would make it difficult for him to defend himself at a full trial.

Singh was initially refused leave to appeal, but Eady’s interpretation was rejected by Lord Justice Laws, who said Eady had risked swinging the balance of rights too far in favour of the right to reputation and against the right to free expression. Laws described Eady’s judgment as “legally erroneous”.

Many scientists and science writers have rallied to Singh’s support, claiming that the freedom of scientific opinion is at stake.

Speaking after the judgment, Singh said this was the “best possible result”.

“Simon Singh’s battle in this libel case is not only a glaring example of how the law and its interpretation are stifling free expression, it shows how urgent the case for reform has become,” said Jo Glanville, editor of Index on Censorship.

Editorial Commentary:

The CDC (Centers for Disease Control) has been begging conventional medicine to stop overprescribing antibiotics for decades. Even so, a recent study in the Journal of Hospital Infections found that 37% of 600 antibiotic prescriptions were considered unnecessary and another 45% were considered to be inadequate.

Considering that antibiotic use in infants has been associated with doubling the incidence of asthma, and other studies have revealed that 76% of adults who visit a primary care physician because of a sore throat are given an antibiotic, even though viruses (that are not affected by antibiotics) are the primary cause for upper-respiratory-tract infections.

The problem is twofold: patients want their doctor to *do something* when they are sick (magic bullet) and don’t always appreciate hearing that they need to drink fluids and rest while their body heals itself. So often they press the doctor for antibiotics.

The second problem is that many doctors *cave in* and provide useless prescriptions for antibiotics. Some MDs have admitted that they do this because the patient pressures them, or are fearful they will lose a patient. Understandable. However, this is what contributes to the development of antibiotic-resistant bacteria.

Perhaps it’s time that medicine *grows a spine*, and elevate themselves to the same evidence-based standards that they demand from our profession.

You will find many more articles like this at the Antibiotic Abuse Page.

There’s a lot more info like this in the Section

Editorial Commentary:

The World Health Organization (WHO) recently crafted and published the WHO Guidelines on Basic Training and Safety in Chiropractic (FULL TEXT Adobe Acrobat 512KB) in consultation with the World Federation of Chiropractic, the Association of Chiropractic Colleges and various chiropractic, medical, osteopathic, and other groups. [1]

The Guidelines make it clear that chiropractic is a separate profession rather than a set of techniques that can be learned in short courses by other health professionals.

They also make it clear that medical doctors and other health professionals, in countries where the practice of chiropractic is not regulated by law, should undergo extensive training to re-qualify as chiropractors before claiming to offer chiropractic services.

In some countries there have been recent efforts by medical groups to provide short courses of approximately 200 hours in chiropractic technique. The WHO feels this is an extremly bad situation.

The World Health Organization guidelines indicate that a medical graduate should a require an additional minimum of 1800 class hours, including 1000 hours of supervised clinical training, before claiming to offer chiropractic services. [2]

REFERENCES:

1.   World Health Organization Guidelines on Basic Training and Safety in Chiropractic
http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf (Adobe Acrobat)

Editorial Commentary:
Are German Orthopedic Surgeons Killing People With Chiropractic?

Editorial Commentary:

Chiropractors pride themselves in their ability to diagnose and manage neuro-musculo-skeletal (NMS) complains. According to all the surveys, this is our bread and butter, and no one on the planet is better trained to diagnose (locate) and treat (correct) neck, low back, or peripheral joint (knee, elbow etc) complaints. But, don’t take my word for it.

Orthopedic surgeons are supposed to be the *gods* of medicine, the pinnacle of medical knowledge. First they become MDs, then rotate through a variety of specialties, and finally take residence in an orthopedic program. You may want to review this interesting description of the requirements for the UCLA Orthopedic Surgery Residency Program.

This is a long and sad tale about the weakness of modern medicine. And the following articles were all published in the prestigious Journal of Bone and Joint Surgery, the number one journal for orthopedic surgeons.

In 1998, two medical doctors at the University of Pennsylvania School of Medicine in Philadelphia, contacted all 157 chairpersons of orthopedic residency programs in the United States. Together they developed and validated a basic-competency examination in musculoskeletal medicine to give to the first year residents. The results were astounding, because 82% of the eighty-five medical school graduates failed this BASIC competency exam!

Four years later they redesigned the exam and again gave it to all the residents. Even though the passing grade was LOWERED from 74% to 70% (plus or minus 9.9 percent), 78% of them again failed the exam, with a mean test score average of 59.9 percent!

To add insult to injury, this exact test was given to a group of 51 chiropractic students during their last semester of schooling. The results? 70% of the students passed the test. This is in contrast to an 80% failure rate for the MDs.

For clarity sake, you should appreciate the difference between the chiropractic and the medical participants in these studies.

• The chiropractic group were still JUST STUDENTS

• The medical group had already graduated medical school, been awarded their MD degrees, completed all their hospital rotations, and finally been accepted into highly competitive orthopedic residencies.
  

One would expect that, during their 5 years of medical training, endless hospital rotations, and residency programs that these doctors *might have* picked up a little more musculoskeletal knowledge along the way. Evidently this is NOT the case.

These medical authors concluded that residents in orthopedic surgery programs are not provided with sufficient training in NMS analysis. The truth is, they are incompetent in musculoskeletal assessment or treatment. This situation was not corrected during the 4-year interim between the publication of the 1st and 2nd article, and likely has not been corrected 11 years later.

The solution? If you have spinal pain, seek care from someone who is properly trained to assess and manage your care. That person would be a chiropractor.

This is an interesting letter from the British Medical Journal:

Scientific heavyweights deplore the NHS money wasted on unproved and disproved treatments used by practitioners of complementary and alternative medicine (CAM), [1 2] but Lewith, a CAM proponent (see previous letter), is cited elsewhere as saying that the BMJ reckons that 50% of the treatments used in general practice aren’t proved, and 5% are pretty harmful but still being used. [3]

His data were taken from the BMJ Clinical Evidence website. A pie chart (see it below in the Evidence-based Practice posting) indicates that, of about 2500 treatments supported by good evidence, only 15% of treatments were rated as beneficial, 22% as likely to be beneficial, 7% part beneficial and part harmful, 5% unlikely to be beneficial, 4% likely to be ineffective or harmful, and in the remaining 47% the effect of the treatment was “unknown.”

The text says, “The figures suggest that the research community has a large task ahead and that most decisions about treatments still rest on the individual judgements of clinicians and patients.” On 9 October 2007 the situation had changed—but not for the better. Treatments rated “beneficial” had decreased from 15% to 13%. The associated text is unchanged.

Acute low back pain is a common and well investigated condition. BMJ Best Treatments reports that back pain affects 70-85% of all adults, and each year almost half of us get back pain that lasts at least a day (http://besttreatments.bmj.com/btuk/conditions/1559.html). There are 18 treatments for acute low back pain which have been tested by randomised controlled trials (RCTs), of which two (11%) were graded “beneficial” and 13 (72%) “unknown.”

The accompanying table shows all of the 18 treatments for acute low back pain and their rated effect. According to this table, a condition that is extremely common, and for which many treatments have been intensively researched, has an even higher than average proportion of treatments that are labelled “unknown” efficacy, or in other places “need further study.” There must be some mistake.

The solution to the mystery is that the label “unknown” does not mean, “We have no knowledge of the effect of this treatment because it has not been tested in an RCT.” Astonishingly, it means, “We have tested this treatment in several RCTs, but on balance there is currently no convincing evidence that it is effective for this condition.” So really the efficacy of these 13 treatments for acute back pain is not “unknown” but “not demonstrated.”

Lewith’s interpretation of the pie chart is highly misleading. The research community has been commendably diligent, but of course RCTs often fail to find that certain treatments are effective. Euphemisms such as “unknown” or “needs more study” for the inefficacy of such treatments may soothe the feelings of proponents of those treatments that have so far failed to show efficacy, but it does an injustice to the researchers who obtained these data, and misleads both practitioners and patients about the extent to which orthodox medicine is evidence based.

It is particularly ironic that CAM therapies are over-represented in the ‘‘not shown to be effective” category, so if anyone should be concerned about lack of evidence it should be CAM practitioners rather than conventional medics.

John S Garrow vice chairman, HealthWatch, The Dial House, Rickmansworth WD3 7DQ johngarrow@aol.com

Competing interests: None declared.

REFERENCES:
1 Kamerow D. Wham, bang, thank you CAM. BMJ 2007;335:647. (29 September.)

2 Colquhoun D. What to do about CAM? BMJ 2007;335:736. (13 October.)

3 Cope J. The great debate. Healthwriter 2007 Apr:1-3.

As long as we’re on the topic of Evidence-based Practice, you’ll enjoy Anthony Rosner PhD’s article “The Shifting Sands of Evidence-based Medicine”.

Robert D. Mootz, DC, who is the Medical Director for the State of Washington Department of Labor and Industries also penned an interesting review in JMPT titled “When Evidence and Practice Collide” (FULL TEXT) that sheds a lot of light on EBM issues.

Add to this the complication that, by JAMAs own standards of evaluation, “between 18 and 68 percent of the 264 abstracts evaluated from major medical journals were inaccurate”. Why is this a problem? Meta-analysis starts with a review of potential materials…and what’s initially reviewed is the ABSTRACT, not the full-text article.

Lastly, it has been stated, by the editor of BMJ (the prestigious British Medical Journal), that “only about 15% of medical interventions are supported by, solid scientific evidence”.

That’s all old news. What’s current?

This is from a more recent (2007) BMJ Survey: Of around 2500 (medical) treatments reviewed, 13% were rated as beneficial, 23% likely to be beneficial, 8% as trade off between benefits and harms, 6% unlikely to be beneficial, 4% likely to be ineffective or harmful, and 46%, the largest proportion, as unknown effectiveness (see figure 1).

None of this is an excuse for us to be negligent in developing clinical guidelines and evidence-based practice parameters, but excuse me while I ask “why are you expecting US to maintain a higher standard then you do?”

There’s a lot more info like this in the Section

You can find it all with our Section

After enjoying John’s posting on the Canadian BCA/Singh case, I feel it’s time to pour some gas on the conversation, to heat things up a bit.

First, you can review the articles under consideration at the Chiropractic and Infantile Colic page.

Then, read Anthony Rosner, PhD’s delightful article “Fables or Foibles: Inherent Problems With RCTs“, as he points up the issues of testing “manual medicine” by RTC.

Finally, you can review previous “failures” in developing a truly inert sham adjustment.

I don’t envy researchers who must overcome these obstacles, but in the mean time, there’s no shame in relying on Case Studies and retrospective treatment reviews to help ground us in reality while we design a treatment plan.

Previously I wrote about the British Chiropractic Association suing science writer Simon Singh for libel. This has been widely criticized as a tactical mistake due both to the expense and to the negative publicity which has thus far ensued. The BCA has recently produced a list of evidence justifying the chiropractic treatment of children with asthma and colic which evidence-based blogs have proceeded to, for want of a better term, eviscerate. One of the criticisms was for the BCA not including a study which showed manipulation to be no better than placebo for infantile colic.

Continue reading …

Modafinil is a popular drug used by people who want or need to stay alert. It has become a popular stimulant, used by soldiers to stay awake and by citizens looking for a safe brain boost, including one in 10 researchers. The FDA issued their “Approved” stamp for it to be used for treating narcolepsy and sleep disorders in 1998. At that time, scientists claimed that it did not change levels of dopamine in those who took the drug. Increases in dopamine levels are considered a chemical signature of possible addictiveness to a drug. Since its FDA approval, modafinil is now being used “off-label” to treat depression, Parkinson’s disease and fatigue.

However, the March 2009 issue of JAMA published this study;

Volkow N, et. al., Effects of Modafinil on Dopamine and Dopamine Transporters in the Male Human Brain., JAMA, Vol. 301, No. 11, March 18, 2009.

You can read more on this report at the Wired Science Blog.

Vaccination is a controversial topic with chiropractors because of our non-drug and non-surgery approach to health. The Vaccination Page attempts to present both sides of the vaccination issue.

We here at Chiro.org take great pride in providing current, updated and accurate information for chiropractors. In this the latest of my posts about fake journal articles being uncovered, I provide further evidence that what you see, not only on the web but also in “scientific” journals,  my not be all it is presented to be. Great care is an absolute MUST when obtaining information, period, no matter what the source of that information! So to borrow a phase from the only TV Series, Hill Street Blues, “Hey! Hey! Hey! Be careful out there!”

Here at 2 more posts from The Scientist blog reporting, yet more, fake journal news:

Editors quit after fake paper flap

OA publisher accepts fake paper

The “Scientist” magazine blog posted a follow up on a report last week of a division of a ‘fake journal’. Yesterday a follow up post was made stating that the reported journal was not the only one of its type, which bore the imprint of Elsevier’s Excerpta Medica. The follow up post reported there were a total of 6 journals of the type mentioned in the original report. Elsevier issued a statement, which read impart…

“It has recently come to my attention that from 2000 to 2005, our Australia office published a series of sponsored article compilation publications, on behalf of pharmaceutical clients, that were made to look like journals and lacked the proper disclosures,” said Michael Hansen, CEO of Elsevier’s Health Sciences Division, in a statement issued by the company. “This was an unacceptable practice, and we regret that it took place.”

The full posting can be read here;

http://www.the-scientist.com/blog/display/55679/