Spot the Mistake (Chiropractic Edition)(updatedX2)

Let’s play a game! After my little blurb, I’ve posted something seen in a presentation made by a medical student, on chiropractic. In the comments post all the ways in which the student’s comment is wrong.

Some background: At my med school, there is a senior elective class where one can independently study and research an area of health care that isn’t covered in detail in our curriculum. This student chose chiropractic. Specifically he chose “Evidence based medicine applied to chiropractic.”

Disappointingly the presenter was not up on how to read or understand evidence based medicine.  It’s disappointing because the student in question is an “honors” level student, and will be going on to do his residency at Mayo clinic, in a very competitive speciality.

Among other things, he took Cochrane reviews, and called them biased. He didn’t identify any particular bias. He just picked the author of the Cochrane review and said that this author was against chiropractic. Throughout the presentation he had scattered statistics that “proved” the usefulness of chiropractic.

The worst part of all this, is that his presentation was supposedly reviewed by a clinical professor BEFORE the presentation. I’m hoping that the doctor in question was just busy, because if not, some attending at my school has some ‘splainin to do.

At any rate, I’ve presented the text of the worst slide below. In the comments, post why you think he’s wrong. If possible pop a reference on, but there are multiple right answers that don’t require any research at all!

Chiropractic is, hands down, safer than conventional therapy!

  • The rate of the worst complication (vertebrobasilar artery dissection) is at best 1 in 10000.
  • Compare this to a 0.4% mortality rate with chronic NSAID use.

There are lots of ways in which this is wrong, pick your favorite.

Hint: More than one of the reasons this is wrong are completely independent of the accuracy of the statistics he provides.  That is, the rate of vertebral artery dissection really could be 1 in 10000 (which I doubt, but research to follow with my answers tomorrow) and he’d still be wrong.

 

Answer to follow tomorrow, with a little bit of research blogging thrown in for good measure.

 

UPDATE:

Totally slipped my mind when I initially posted this. There is also a highly entertaining post over at Science Based Medicine on Chiropractic.

If you end up reading through the comments you’ll see that not all doctors understand anything at all about science.

UPDATE 2:

This is probably going to be hard to pick out without the context of the presentation around it. I’m looking for problems with the actual comparison of the rates given. This is not an apples to apples comparison, and he should have known better.

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34 Comments on “Spot the Mistake (Chiropractic Edition)(updatedX2)”

  1. ScienceTeacher Says:

    Does it count if my favorite wrong thing is the horrible pun, “hands down”?? ;)

    (Side note: no, I’m not a doctor, so please don’t laugh if I’m wrong – but identifying one thing as “the worst complication” seems to oversimplify it – my layperson brain is telling me there are probably multiple really, really bad possible complications. But that’s probably because I’m “biased against chiropractic”!)


    • That’s one of the many right answers :)!
      He’s ignoring all other possible complications of either therapy.

      There’s more though. I don’t think I’ve given enough information for people to get them since they lack context of the rest of the presentation, so in a bit I may post some hints.

  2. MXH Says:

    uhh, who cares about complications if it has no proven benefits to the patient??

  3. MXH Says:

    Just off that slide, I’d be pretty disappointed if the student got a good grade for this presentation.

  4. leigh Says:

    wtf does chiropractic have to do with inflammation that justifies mention of NSAID use? this is an invalid comparison. is this person talking about treatment of pain? and if so, why are we assuming the pain is solely due to inflammatory processes?

    the worst complication is only one of the possible list of complications. how many are there, and how bad are they in comparison to the medically indicated therapy for the condition in question? (which we still do not know)

    the “at best” phrase re: the worst complication rate seemed entirely out of place. in fact, if a doctor said to me s/he “at best” had a complication rate of xyz, i would not walk, i would run away.

    are we comparing safety in terms of mortality, long term risk/benefit, short term pain (assuming again we are talking about pain) relief- what? this is not defined.

    k, those are all of my current dissertation-break thoughts.


    • Well, thats my fault for not providing more context. While your first paragraph of critcisms are valid, If i’d thought to give you context, it would have told you that this is in reference pain.

      The first step therapy would be short courses of NSAIDs for most doctors.

      Your second paragraph is indeed, critical to the problem at hand. What about other complications? What’s the MOST COMMON complication, rather than the worst.

      The “at best” is just bad writing. He meant that the highest estimate he could find of the incidence of vertebrobasilar dissection was 1 in 10000.

      Your last paragraph is, again, absolutely on point. He didn’t clearly define how he was guaging safety. Infact, he’s inconsistent in how he gauges saftey. That’s part of the answer as well.

  5. ddw11 Says:

    Could it be that no matter how small the risk of stroke/arterial dissection the risk:benefit ratio of cervical manipulation will always be infinite because there can be no expected benefit from cervical manipulation in a reality/evidenced based assessment, while NSAIDS have a well established mechanism of action and a long history of proven efficacy?


    • Thats good too, not one I’d thought of though.

    • JLK Says:

      I do not understand this paragraph at all. LOL.

      Can someone translate this into layperson English for me?

      • catgirl Says:

        Basically it means that since chiropractic provides no benefit, any amount of risk is unacceptable. However, since NSAIDS can actually be effective, it is worth a small amount of risk.

      • ddw11 Says:

        I am saying that based on our knowledge of pathophysiology and the evidence from trials of chiropractic subluxation, there can be no reasonable expectation of benefit from cervical manipulation. Because there is no benefit, any risk of injury, no matter how small, is too much risk.

        The same is not true of treatment with NSAIDS. There certainly is risk of complications with NSAID use, even death. However, this risk is weighed against a certain expectation of improvement that has been shown to exist in clinical trials.

        • JLK Says:

          Thank you! (From the non-doctor, non-biomed social psychologist who still finds this stuff interesting when she understands wtf is going on.)
          :)


    • This is similar to my point about Zicam. It has little or no benefit, but has a small, but measurable serious risk (anosmia). Let’s make this clear. All medications, procedures, or even walking into a hospital has a statistically significant risk (from low rate of a small complication to large risk for a serious adverse event). I know there is a risk to NSAIDs, which I mitigate by limiting use, but I know there is a scientifically researched benefit to its use.

      Chiropractic, other than being a good massage, has no benefit whatsoever, but has some level of small risk. For me, there isn’t anything else to say.

  6. titmouse Says:

    The student seems to feel that “bias” equates with holding an opinion. And in his view, people shouldn’t take statements from biased parties very seriously.

    However, if this were our policy generally, civil discourse would come to a screetching halt. Only the ignorant who don’t know enough to form opinions would merit out attention.


    • The Titmouse lives! I was worried you were gone forever.

      I used a variation of this argument in conversation with the student who presented this.

      He didn’t get the point. He also didn’t understand that “well 8 trials show a positive effect, and only one metaanalysis (including the trials just described as positive)showed no effect” is an argument AGAINST chiropractic being effective.

  7. Tim Kreider Says:

    Ugh, how disappointing. Must have been tough for you to sit through that!

    Presumably the 1 in 10000 is a rate of complication per manipulation or per visit. Comparing that rate to the rate of *chronic* NSAID use is comparing apples to oranges. Surely the mortality rate *per administration* of NSAID is much lower than 0.4%.

    Likewise, the dissection rate for *chronic* visits to chiropractors may be different; if you get manipulations regularly for years, your chance of dissection over that time is likely more than that 1 in 10000.

  8. JLK Says:

    You know, given all of the discussions going on around the country right now regarding cost and waste in healthcare and how we can make things more efficient and beneficial…..

    I would like to know the cost:benefit ratio comparison for chiropractic vs. NSAID.

    Especially considering that I have never known anyone who has gone to a chiropractor and NOT continued going for years and years. I used to have the theory that they purposely don’t make you better so that you have to keep coming back. And I was 14 when I came up with that theory.


    • JLK, sadly a lot of third party payors are including alternative therapies in their reimbursements. If there is no benefit, then the risk benefit ration goes to infinity (meaning any risk is bad), and its costing our healthcare finance system lots of cash that could be better spent on fixing issues like the transplant system.

      Why do we need to spend another dollar researching the cost:benefit ratio for chiropractic, when nearly every peer-review study shows it has no benefit whatsoever? I don’t mean to pick on you, but honestly, there isn’t one alternative therapy that actually works. We’ve spent 10 or so billion dollars at NCCAM finding these results.

      • JLK Says:

        Michael, I’m not sure why you would think I’d feel you were picking on me. I’m in complete and total agreement with you. My question about cost:benefit ratio for chiropractic was mainly rhetorical, because I already know that chiro care is infinitely more expensive than NSAID.

        It’s funny (not really), because my insurance company covers chiro and acupuncture. But as I said on a previous post, it won’t pay for the Gardasil vaccine against HPV or Chantix for quitting smoking.

        And that crap pisses me off.


        • I agree with you then. Insurance companies aren’t into preventative medicine, because hardly anyone sticks with an insurance plan for an extended period of time. So paying for a long-term solution has no financial benefit for the health plan.

          This is where I think a national system of health care makes sense. I don’t care if its privately or publicly managed, but there has to be investment in long-term health. Gardasil’s effect is 20 years down the road, and we should pay for that. Weight loss is another (think of all the diabetes, heart disease, and other things could be prevented).

          And it ticks me off too. High five!

  9. catgirl Says:

    Well, this is kind of minor compared to all the other great points that others made, but just the presentation of the numbers seems to be intentionally unclear, which is very common in reporting statistics. The rate of the worst complication with chiropractic is 1 in 10000, but also 0.01%. I don’t know if that makes it seem better or worse, but it’s certainly more clear to put the numbers in the same format.

    • Esattezza Says:

      Here here, catgirl! I see that kind of misdirection on autism message boards all the time and it drives me nuts. “The rates of autism used to be between 5 and 6 in 1,000 20 years ago, don’t you know! And now it’s 1/150 or so!” OMG it’s an epidemic!” Hmmm… ~.0055% compared to .0067% that huge of an increase couldn’t possibly be caused by increased awareness or improved diagnosis!

      • catgirl Says:

        Actually, 5 per 1,000 is the same as 1 in 200. 6 in 1000 is 1 per 167. if those really are the rates from 20 years ago, that’s almost identical to 1 in 150 or so.

  10. Dustin Says:

    While I might be reading it wrong, it looks to me like one of them is the rate of complication of the treatment while the other is the rate of deaths while the person is taking the treatment.

    If this is what he is saying then it would be like saying that the number of people who drowned in the ocean is lower then then the number of people who died in the ocean. That would be an unfair assessment because complications is only a subset of causes of death, the patient could have also died from whatever illness was trying to be treated.

    Of course I could be completely off-base, medical terminology not being anywhere close to my strong point.

  11. Nick Says:

    I think alot of bloggers have gotten off track and are on a chiropractic witch hunt here.

    Spinal manipulation (performed by osteopaths, physical therapists, and most often chiropractors) and /or NSAIDS are the evidence-recommended first lines of therapy in uncomplicated LBP and neck pain. A combination of exercise and manual therapy is more effective with necck pain w/o radiculopathy than manipulation alone.

    If you would like to educate yourself on neck pain and evidence based care, read the summary articles in Spine. You may be surprised(or not) of the efficacy and safety of spinal manipulation of the cervical spine and the lack of support for many other treatments.

    Read summaries in Spine. 2008 Feb 15;33(4 Suppl):S123-52. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.

    Side note: I know many (not all) chiropractors that discharge patients and don’t see them forever. Patients usually return to their care because they have a new injury or another episode of their symptoms.

  12. Katherine Says:

    It’s funny, whenever my parents get back or neck pain, they treat it themselves at home for free by doing a variety of stretches (there are different stretches for different areas of pain obviously). And after a few days or weeks everything is better and the (free) stretches are not needed until the next time there is pain. So Nick, why is specialist, expensive manipulation needed again? Especially since I would think that these stretches would have a similar effect to chiropractic manipulations but with a fraction of the side effects.

    Anyway the point of this blog post is that obviously the med student doesn’t know how to practice evidence-based medicine, and the fact that this was about chiropractic is coincidental (perhaps ;))

  13. Nick Says:

    Katherine,

    Thanks for your post. I will try and address a couple points for you just to put this aside to bed.

    It does seem that there is a dearth of public knowledge on spinal manipulation and a strange stigma associated with it in the U.S. You see it accepted and utilized much more in Europe and Australia.

    1) In most cases, proper exercises and/or stretches will help neck pain. A patient should seek care if they are having severe symptoms or after a short duration (2-7 days) of unrelenting symptoms. Question: Where does the general public get those exercises?

    2) If that patient does seek care, you would like them to utilize the most appropriate/evidence/value based therapy or practitioner. If you know or ask many practicing family MD/DO’s, you would find that not only is musculoskeletal care not their strongest area but they usually don’t enjoy seeing that patient type. My last post described the overwhelming evidence stating spinal manipulation/chiropractic manipulation be used used first in uncomplicated cervical pain.

    3) I am not sure where you have received information on spinal manipulation being “expensive”. If you are eluding to the chiropractic profession being expensive, you will find that they are actually more cost effective when compared to medical care in spine pain. Increasing amounts of research shows this.

    Sorry for this getting long. Some things need to be looked at without older, prejudiced glasses. Especially those that will be our future health care providers.

    Good day.


    • I’m afraid I disagree with you in almost every particular Nick.
      This is your warning, nothing resembling medical advice can be offered, without (at the very least) a disclaimer saying to check in with your doctor!

      For example, you cannot say

      1) In most cases, proper exercises and/or stretches will help neck pain. A patient should seek care if they are having severe symptoms or after a short duration (2-7 days) of unrelenting symptoms.

      Please read the disclaimers, when you say something is supported by research, you mustprovide a citation.

      The rest of your comments, I will address in a new post because it’s far too long for a comment.

  14. Nick Says:

    Whitecoattales,

    My post was not medical advice. It was regurgitation of the information in journal articles and publications on spinal pain. The list of citations would get quite long so I will add just a few at the end of this post. My #1 you highlighted is basic spine pain guidelines in the countries of Scotland and Australia, and is almost universally accepted in spine research. Again, it is not medical advice but general knowledge that the public should be aware of.

    I agree that this blog has gotten a bit long, but I would be interested in your comments since it looks like my words and references struck a nerve. This should be a sharing of thoughts and knowledge, not a place to bicker.

    [1] Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic
    review and best evidence synthesis. Spine J 2004;4:335–56.

    [2] Bronfort G, Haas M, Evans RL, Bouter LM. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Spine J. 2008 Jan-Feb;8(1):213-25.

    [3] Buchbinder R, Staples M, Jolley D. Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine. 2009 May 15;34(11):1218-26; discussion 1227.

    [4]McGill SM. Low Back Disorders:Evidence based prevention and rehabilitation. Champaign, IL. Human Kinetics Publishers, 2007.

    etc, etc, etc…


    • A regurgitation of information from a medical journal absolutely constitutes medical advice.

      Here’s the line: If a person googled a random term, found this page, and read ONLY your comment, without context, could they walk away thinking they now didn’t have to ask their healthcare provider a question they would have otherwise asked. If they don’t think they have to ask that question anymore, it’s medical advice, and requires a disclaimer in the same comment.

      I know that the majority of readers who find by blog by search engine are searching for answers to questions they should really be asking a doctor, and won’t be responsible for their being misinformed, or misinterpting good information. The internet is good for alot of things, medical advice isn’t one of them.

      I will certainly take a look at these papers as well, but I find it odd that you’re placing this comment here when I’ve written an entire post addressing the last journal article you cited.

      I feel that your previous comment, was misleading because you’re saying that it was scottish and australian guidelines for backpain, but you’ve placed it with a citation from spine that doesn’t endorse that point of view at all.

      Also, you are confusing “Stuck a nerve,” with “has rules that need to be followed.”

      When it comes to Chiropractic, I don’t feel scottish and australian guidelines are relevant. Chiropractors in those countries don’t have the same education or same political agenda as chiropractors in this country. The same goes for Osteopathic doctors, who are primarily evidence based medicine practioners here, but that cannot be said in europe.

      Further, I was under the impression from your previous comments that you were in the US, why not use american guidelines? Or am I incorrect in your location?

  15. Nick Says:

    Opps. I will make further comments on the new post. I am fairly new to blogging and did not realize.


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