Sending your child to the chiropractor: Be very careful

Sending your child to the chiropractor: Be very careful

There are plenty of things we don’t know about health and illness. Sure, we know a lot more than we did fifty or a hundred years ago—but every day, still, I have questions that aren’t yet answered. I read a dozen or so journals each month. (I know. Nerd.) Each one has at least ten or so good quality studies—good, solid experiments to determine the best way to treat something, or basic science investigations to really understand what’s going on in the body. Heady stuff. And there are always more questions!

A question was posed to me this week: can chiropractic treatments help with scoliosis? My first thought was: probably not. I mean, I’ve never run across a study of chiropractic in my journals that shows effectiveness for scoliosis. Still, I wondered—what about the chiropractic journals? They have their own literature. Why not take a look?

I looked. And I am appalled. There is nothing—nothing, not a shred of evidence—that chiropractic can help scoliosis. One trial has been published involving all of six pediatric patients. That’s it? These are people who routinely treat children, who routinely treat back problems, and who are giving people the impression that they can help with scoliosis. And they’ve barely even studied it!

OK, maybe that was an isolated thing. So I dug more. I ran across a series of three published reports, all in established chiropractic journals, that together have reviewed the entire chiropractic published literature on pediatric care. Keep in mind, this is chiropractors themselves, reviewing their own knowledge base.

The first review, published in 2005, is titled Assessing the evidence for the use of chiropractic manipulation in paediatric health conditions: A systematic review. Chiropractors Gotlib and Rupert of the Canadian Chiropractic Association searched the entire biomedical literature, looking at everything that had been published using every database imaginable, to find all articles relevant to children.  Their “inclusion criteria” were quite broad—they looked for any study involving children in a therapeutic setting that was published in a peer reviewed journal or reported at a conference, or any relevant systematic review. They found 166 published reports, almost all of which were “descriptive studies”—the lowest kind of evidence, where an author describes what was seen or done, without any corroboration or experimentation that what was done was effective. As for high-quality evidence, through 2003 only NINE randomized trials in children of chiropractic care for any pediatric health condition had been published. One was only a feasibility study that didn’t report results; one was on nursemaid’s elbow, which isn’t treated with chiropractic spine manipulation. Of the remaining seven studies: four showed no effect on asthma, bedwetting, colic, and jet lag; and three showed benefits in asthma, bedwetting, and colic. The total number enrolled in all 9 clinical studies was 590 children. The authors concluded:

“Health claims made by practitioners regarding the application of chiropractic manipulation as a health care intervention for paediatric health conditions are, for the most part, supported by low levels of scientific evidence.”

The same authors compiled a second review in 2008, to catch any studies published from January 2004 thru June 2007. They used the same exhaustive search, and the same broad criteria. They found ONE additional randomized trial—which was, actually, only a feasibility study involving six children with scoliosis. Their conclusion:

“There has been no substantive shift in this body of knowledge during the past 3 1/2 years. The health claims made by chiropractors with respect to the application of manipulation as a health care intervention for pediatric health conditions continue to be supported by only low levels of scientific evidence.”

OK, this is looking bad. Real bad. Is anyone actually even trying to study children to figure out if chiropractic works, and when to use it?

A second group of authors picked up the baton, publishing their own thorough review in June 2012, specifically to see what new trials concerning children had appeared. There was quite an uptick in publications—from the four year span since the last review, from 2007 through 2011, sixteen studies were published about children, looking at a total of 1980 kids. About 500 kids a year were actually enrolled in clinical studies. It is a step in the right direction. However, many of the studies were poorly designed and difficult to interpret, according to the chiropractors who wrote the review. And ironically, there have been ZERO published studies, ever, looking critically for genuine evidence that Spinal Manipulative Therapy helps children with back pain. These authors concluded:

“Further research is clearly required in this area of chiropractic health care, especially with respect to the clinical effectiveness of SMT on pediatric back pain.”

I am glad that the chiropractors who compiled these three reviews have expressed their need for better pediatric studies. They’ve illustrated that their own profession has neglected children. They have essentially no evidence that any of their treatments work for any pediatric condition. However, at the rate they’re going, the tiny dribble of studies being published isn’t going to come close to a decent, reliable body of literature any time soon. A single issue of Pediatrics contains far more studies looking at far more children than the entire accumulated published experience of the entire chiropractic profession.

A caveat: these reviews of the chiropractic literature included all publications through the end of 2011. It is possible that 2012 saw an explosion of pediatric studies. I’d love to hear that, if it’s true. I don’t have subscriptions to these chiropractic journals, and don’t have the ability to completely review their 2012 literature myself.

Chiropractic professionals need to decide. Is treating children part of our practice? If so, they should insist on quality information to guide their practice to effectively help pediatric patients. Until they have that knowledge, they ought to tell parents that, honestly, they have no idea what they’re doing.

Roy Benaroch is a pediatrician who blogs at The Pediatric Insider. He is also the author of Solving Health and Behavioral Problems from Birth through Preschool: A Parent’s Guide and A Guide to Getting the Best Health Care for Your Child.

Image credit: Shutterstock.com

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  • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

    yet, patients happily shell out cash money for chiropractic care.

    Physicians are lambasted for not practicing EBM. We’re even being told that our pay will be cut if we don’t follow some “high on the mountain” decree of the “standards of care,”

    Chiropractors, herbalist, naturopaths, and all other manner of “providers” can spout off any gobbledygook they wish without reprisal.
    essentially practicing with almost NO oversight or government interference of regulation.

    all of this and these practitioners still often garner more respect than Doctors from the public.

    we have done a poor job indeed of protecting the sanctity of our profession and educating the public to not be so gullible.

    and Dr Oz is not helping….

    last I checked… Rattle snake poison is natural too, it don’t make it good for you!

  • http://www.facebook.com/profile.php?id=100002068609139 Michael Brown

    Our Family Practice refers to a Chiropractic office located in the same complex as us quite often. Here’s what I can say about our experience with them: They focus exclusively on the treatment of musculoskeletal ailments in adults – and they do a great job. Their treatments are effective, the care plans are often concise, and they are very good diagnosticians. For a number of challenging musculoskeletal conditions, they tend to be our go-to specialists.

    I feel as though there is a split within Chiropractic. There’s practices like the one I describe above. They’re well-integrated with the medical community, use evidence-based treatments, and are a pleasure to work with.

    Unfortunately, if I may generalize, there’s a second type of Chiropractic office. These offices diagnose “birth trauma” subluxation injuries in young children, supposedly treat allergies and asthma, shun vaccines, and sometimes even discourage patients from taking medications prescribed by an MD or DO.

    I don’t know how long Chiropractic can survive with this weird divide. The evidence-based practice which expertly treats musculoskeletal health could and should fill an important niche in health care. The second type of Chiropractic office offers no benefit, as near as I can tell. We’d be better without them.

    • Andy

      I agree with your assessment. The rift in the chiropractic profession is very wide. There are the medical chiropractors (what I’m going to practice) and then there are the “straight” chiropractors. “Straights” only treat “subluxations” and only manipulate the spine. It’s a religious cult and is very sad. I would have to say that my school, an evidence-based chiropractic school, is about 50/50 in terms of student population. I am part of the medical 50%. There are some real interesting practitioners out there. It’s a long and sad discussion, really.

    • http://ClinicalPosters.com/ ClinicalPosters

      Chiropractors and medical doctors each have their advantages. The only issue is when either prevails upon the other’s territory. It’s sad when patients are caught in the middle of the chest-beating wrangle.

  • Andy

    I am a chiropractic student and scientist. I am nearly finished with my education and am primarily in clinical internship. I absolutely agree that the entire chiropractic profession must step up in regard to research. There are surprisingly few researchers in the field as is – Dr. Scott Haldeman MD, DC out of UC Irvine and Dr. Frederich Carrick of the Carrick Institute have contributed to general manipulative research. Other than those two (and a few others whose names I have forgotten) most of the peer-reviewed studies I have come across are efficacy studies, showing that, in general, spinal manipulation is a low-cost and potentially effective methof of treatment for low back pain, headaches and neck pain.

    Being in a chiropractic practice is interesting. I am also simultaneously an Acupuncture student and have been a practicing orthopedic/medical massage therapist for over 13 years. There are quite a few cases of people being helped in what I would consider scientifically unexpected ways. This is what I want to figure out how to study after graduation. Right now most of the chiropractors I have worked with or talked to have a lot of these testimonials. While I appreciate that it helps patients and am very happy that these people find the relief they need I want to figure out why. That is what is still missing in manual therapy in general and in chiropractic specifically. Valid scientific evidence is still missing. Apparently, thanks to this write-up, the science is missing even more in pediatric chiropractic. Anyone care to help me design some potential studies?

    • Docbart

      What if you find that chiropractic efficacy equals that of a placebo? What will you do with the rest of your career?

      • http://lloydchiro.com LloydChiro

        That’s a tough question! As a chiropractor, I’ve been very happy with my results in practice. But to answer your question as a hypothetical, the chiropractic physician’s training and scope of practice is broad enough that a DC could essentially practice physical therapy, and draw upon their evidence-based guidelines.

    • danielle

      perhaps it’s not chiropractic that is the issue but the scientific studies that are. science likes reductionist empirical information even though everything about the human body interacts and relates with multiple systems. I think we need to rethink the tools (scientific evidence) that we use as the end all be all to what works and what does not work.

  • Phil Hallett

    Why are you worried so much about how much a parent spends on chiropractic care? Isn’t our current health care crisis due to the cost of medical care? Just answer this: how many chiropractors’ offices have you visited? Have you done any investigation that didn’t involve sitting in front of a computer monitor? You never alluded to any risks associated w/ children receiving chiro care. DCs are licensed health care providers who have stood the test of time.

    • http://www.facebook.com/profile.php?id=100002068609139 Michael Brown

      Non-evidence-based Chiropractic care for children still costs money. How should I feel about my tax dollars being used to fund CHIP and Medicaid plans which cover this treatment? I’m a huge advocate of public health plans such as these. All children in our nation deserve access to high-quality healthcare providers. I also believe all health plans should provide coverage for Chiropractic.

      However, just as an insurance carrier won’t authorize off-label use of an expensive branded medication, or the placement of a cardiac stent unless certain criteria are met, payment for Chiropractic should be restricted to conditions for which there is evidence of efficacy.

      Of course if a parent wishes to spend their disposable income on this treatment, without the involvement of insurance, more power to them.

      • Phil Hallett

        Thanks for your honest response. The public health dollars are being wasted on the ER visit for a bandaid. As a chiropractor I’m not interested in billing/insurance games. I try to help improve the quality of my patients’ lives. And they ARE willing to pay out of pocket. Innovators in all walks of life are rewarded in what’s left of this capitalistic system. What works will win out at the end of the day.

        • Mark Lopes, DC

          in California there are no public dollars going to chiropractic care coverage. Parents choose to take their children to chiropractors because they often receive better perceived results than they do from their medical counterparts.

          • Phil Hallett

            Exactly. It seems in this new health care climate of imposing regulations, some MDs think they have to defend their turf. Not to worry, us chiros aren’t interested in allopathy. The paternalistic attitude is what I don’t appreciate.

    • http://twitter.com/PedInsider Roy Benaroch MD

      RE: your rebuttal “DCs are licensed health care providers who have stood the test of time.”– is that good enough for you, as a chiropractor? Are you satisfied that DD Palmer’s theories (late 1800′s) explain what you need to know about how the body works? Aren’t you curious to test what you’ve been taught, and to find new techniques, and new ways to help people?

      Do you tell your pediatric patients, “We don’t really study or test these things in children, but they’re based on theories from the 1800s and we think they work.”

      • Phil Hallett

        Your train of thought assumes much which you haven’t taken the time to investigate. You haven’t answered my question: have you ever stepped outside your 4 walls to interview and observe an actual chiropractor? Yes, research needs to be done. It is very costly and more difficult than mainstream medicine. The federal govt and pharma provide your funding. Also, it is a fallacy to use the double blind, placebo-controlled model for every type of study. This model was designed for drugs where the stakes are HIGH. You know, like Heparin? As far as advancing our applications or techniques, that has been on-going. How much research would be sufficient for you to accept that chiropractic is a reasonable intervention for people of all ages?

        • http://twitter.com/PedInsider Roy Benaroch MD

          I haven’t taken the time to investigate? I read chiropractic journals and summarized your literature, similar to how I’d research a medical topic in the medical literature. That’s because my post is about the lack of pediatric information in the chiropractic literature. I’m sorry if that’s confusing for you.

          I have been to two chiropractors in my life; neither experience was particularly helpful, but it would be unfair and inappropriate for me to generalize based on those experiences. I’m sure there are many chiropractors who sincerely want to help their patients. I believe they’d be more likely to be genuinely helpful if they studied their interventions critically, rather than making stuff up.

          The double-blind, placebo controlled study is an important tool, but not the only kind of research from which people can learn. You’re tossing that in as a straw-man: I never claimed that chiropractors should exclusively rely on those, or that other kinds of study are invalid.

          Research can be expensive, I agree. Consider applying for a grant from the NIH’s NCCAM, the center for complementary medicine with it’s 128 million budged for FY 2012. I’ve also found through a quick google search several philanthropics and other organizations that look eager to fund studies in areas like chiropractic. The money is out there.

          How much research would be sufficient? It never ends– research is a journey, not a destination. There’s a chiropractic student in the comments who sounds like he’s eager to start down that path. I hope that’s the direction the chiropractic profession wants to go.

          • Phil Hallett

            I asked how much research would be sufficient for YOU to acknowledge a solid place for chiropractic intervention. I suspect more than you would expect from the drug rep. Don’t you have anything better to do? Your profession has enough of it’s own problems. I didn’t write an article about why people shouldn’t go to ‘the competition’. Remember Wilk vs. AMA where AMA was found guilty of violating antitrust laws? Your profession was caught attempting to ‘contain and eliminate chiropractic’. Why? Because of competition. Don’t hide behind a facade of concern for public safety. I’ll compare malpractice premiums with you guys any day.

          • http://twitter.com/PedInsider Roy Benaroch MD

            I don’t understand your sentence, “I suspect more than you would expect from the drug rep.” I do not interact with drug reps, they are not allowed at my practice, and I do not accept gifts of any value from any pharmaceutical firm.

            Would you like to respond to the thesis of my post, that there is very little study of children to support chiropractic care for any pediatric health concern? Or is that fact something that doesn’t really concern you as a chiropractor?

          • Phil Hallett

            I don’t think you quite understand that the chiropractor’s true focus is to detect subluxations and to correct them. (If you want me to expand on definitions I will be happy to do that). A patient of any age may present w/ varying degrees of abnormal curvature or scoliosis. Our work can definitely provide help to that patient: structurally, physiologically, and symptomatic. It is not a treatment for scoliosis per se. If some chiros claim to cure scoliosis on children, then I would not agree with that claim. However, if you are insinuating through your article that chiros are not qualified to even provide care at the pediatric level you are wrong.

          • Molly_Rn

            But the
            subluxation stuff is BS and totally not valid and not scoliosis. Chiropractors are not doctors; they do not have the scientific (real science not the hocus
            pocus stuff) education that physicians have. There are ads for chiropractic cures for asthma, diabetic neuropathies, migraines, etc. in the newspapers
            every day and it is nonsense. Chiropractic is a non-science and just a more sophisticated snake oil sales pitch.

          • Phil Hallett

            I personally agree with your disdain for the average yellow page chiro ads. However, there is a valid place for chiropractic intervention in the marketplace. If you think that spinal nerve interference is so much BS, you should tell your medical and PT counterparts to stop trying to incorporate manipulation into their practices. They should also stop releasing patients from the ER telling them they have a ‘pinched nerve’. You have no idea how much training goes into achieving licensure as a DC.

          • Molly_Rn

            My hair dresser has to have training and jump hoops to get licensed but that doesn’t make her a healthcare professional. Manipulation is just that manipulation of the patient for your profit.

          • http://www.facebook.com/tonyebeldc Anthony J. Ebel

            Have you looked at the education of chiropractors Molly? It actually entails many more hours of study in areas such as anatomy and neurology than even MDs take… certainly many, many more hours than RNs.

            The argument of chiropractors not having a solid education and rigorous standards to get licensed and pass boards… is a ship that sailed a long time ago. May want to take a quick path back to reality.

          • Molly_Rn

            They are learning bunk and I don’t believe they have a greater education in anatomy, physiology and neurology than physicians have. And since my education was grounded in science not in the teachings of some old snake oil salesman from the 1880′s I think my education is betterh than yours. I still say chiropractic is BUNK science. It is not reality.

          • Craig Andresen

            Molly you talk a lot and very strongly about things you know nothing about.

          • Molly_Rn

            You make assumptions about something you know nothing about, namely me.

          • Craig Andresen

            Molly I think it is obvious to anyone who can openly and critically think that you have it out for Chiropractic and that you are not basing your OPINIONS on science and studies that HAVE been done and the growing public DEMAND for Chiropractic services..which renders your opinions irrelevant. Maybe you should focus your energy on being a better nurse or on something positive. Have a great day.

          • Molly_Rn

            Craig, don’t make assumptions based on no knowledge. You don’t know me or what I know or why I think chiropractic is not medicine. I believe that by countering the lies of chiropractic is being a good nurse and also positive if I can get just one person to decide to see an actual doctor instead of a quack. You have no real science just your bullying so now you got some of your own medicine.

    • Mike C.

      It seems odd you are addressing individual chiropractors instead of the issue of the article which is evidence based medicine. At the level of the individual, anecdotal evidence at best only illustrates practice not efficacy.

      I truly wonder if evidence is important to you, which may be an extending reason to other chiropractors and why the research may lacking.

      • http://www.facebook.com/mark.lopes.334 Mark Lopes

        The current idea of evidenced based medicine was concocted by a researcher heavily tied to the insurance industry. Then, when research minded medical practitioners published rebuttals that the evidence should also include practitioner experiences the industry shunned that thought, favoring a research only basis, which is unrealistic, likely to save money on insurance reimbursement. The fact is that clinical practice often leads and research follows. People have problems that research cannot always answer. The absence of proof is not the proof of absence and the majority of medical and chiropractic practice is not strictly evidenced based, so to pick out the chiropractors and not medical practice is one sided. Further, there is more evidence supporting chiropractic manipulation for musculo-skeletal pain than most other practices and those folks were being helped just the same prior to research saying so. Also, children are mostly just small people and likely to respond better than older folks since they heal better and are less chronic.

        • http://twitter.com/PedInsider Roy Benaroch MD

          “The current idea of evidenced based medicine was concocted by a researcher heavily tied to the insurance industry.”

          EBM has its roots in the teachings of Aristotle, Francis Bacon, and Rene Descartes (to name a few.) For thousands of years humans have tried to figure out how the world works by observing and testing natural phenomena. That’s called “science.” EBM = applied science.

          “children are mostly just small people…”

          Children have growth plates, entirely different proportions and biomechanics, and very different ways of communicating. They suffer from completely different causes of pain and problems than adults.

          Sheesh.

        • Mike C.

          It seems we have a fundamental difference in our perception of reality. You maintain “The absence of proof is not the proof of absence,” yet the goal of research is never to seek direct proof, it is in fact to seek the absence of proof as you put it. Only then, if the absence of proof cannot be found and recreated, is the probability of the opposite being true accepted.

          As Dr. Benaroch pointed out, which I appreciate, this is a concept passed down by many statisticians far before pharmaceutical companies were around. However, the notion pharmaceutical companies influence all research defies reality since not all treatments involve prescriptions anyway, and I would imagine evidence, not proof, applies to life in general, not just medicine.

          Furthermore, practitioner’s experience is already apart of almost every clinical study done. Every diagnosis or measurement requires some modicum of experience. The difference is the power of one vs the power of many. To think that everyone’s experience and situation is unique is thoughtful, but unrealistic. After all the article was about scoliosis, an ailment which is very common allowing for comparisons between a large group of people.

          As for your statement suggesting children are just small people, it illustrates truly different beliefs we must have and I fear no amount of discourse would overcome such a rift. If we are the sum of our bodies in balance then never are we more out of balance then when we are children (dying being the exception). Chemically, mentally, and physically children are nothing like their adult selves.

    • Molly_Rn

      I know this is antidotal, but I know of two people who died because they chose to go to a chiropractor instead of a real physician. One had non-Hodgkin’s Leukemia and the other had a Circle of Willis aneurysm. So it bothers me that they went to a quack instead of getting the help they needed and supsequently died as a result. The gal who cuts my hair is licensed, but she isn’t boarded in nursing like I am. There is a difference between licensed and boarded. Most physicians go through the time and effort to be boarded.

      • Dr M

        Molly, You are an idiot. Please, Im glad you have an antidotal story about 2 people dying. Over 500,000 die from bad drug interactions and that is documented. Not real doctors? Do you even understand how our educational system works? A doctorate is a level of education not a profession. Where did you get your Rn from a online source? The evidence has been in for over a century. We would gladly wager our licenses against yours if you ever want to really spend the funds to do a real comparison for the treatment of many conditions we treat. Egos like yours need to get out of health care. Myself and many of my colleges have success where medicine has failed. I have many MDs who come to see me. Very happy I might add. There is room for all care providers when some people get off their high horse and do whats best for the patients. You have no idea.

        • Mike C.

          …says the person tossing out arbitrary insults.

        • Molly_Rn

          People have been playing 3 Card Monty for over a cnetury but it doesn’t make it right or science. You are not equivilent to a physician. Your education is not based on actual science. Sorry but you are not a real healcare professional.

      • Phil Hallett

        Chiropractic care is so safe that our malpractice premiums are a fraction of our medical counterparts. Insurance companies could care less about politics. Any intervention has risks. You can’t hold us to a higher standard than you hold yourselves.

        • Molly_Rn

          There is a huge difference between a medical intervention and chiropractic. Don’t trust you as far as I could throw you over my back with one hand. You are not doctors nor are you an equivilent. You sell snake oil dressed up as manipulation. You say you cost less, but then have the pateint come back forever so ultimately it costs the same.

  • http://twitter.com/PedInsider Roy Benaroch MD

    Where’s the hater-speak in my post?

    I very specifically looked in the chiropractic literature to see what kinds of studies of chiropractic therapy have been done in children. As documented by the chiropractors whose reviews I quoted, there is very, very little study being done on children. I have pointed out this truthful statement, and have asked that chiropractors themselves be truthful with their patients about the state of their knowledge.

    At least one chiropractor here in the comments (and a few who posted on my blog) have agreed with me, and are seeking to improve their knowledge to better help their patients. Good for them. I hope these science-minded, health-focused individuals become chiropractic leaders, to best help their own profession and their patients.

    • Jay Greenstein, DC

      Roy, look at my post. I agreed with you that we don’t have enough science, but the medical community also does not have enough for all the treatments that are being done on patients either, but you neglect to report that. Your report is biased, plain and simple. Just because I don’t agree with your conclusions (why did you reference pediatric back pain in a scoliosis article?), doesn’t mean I’m not “science minded.” Do your homework on me and see the work I’ve published and presented, my practice, my clinical research foundation etc. We collaborate with major universities on our clinical research. It’s because of my work in research that your article pisses me off. If you really wanted to do something worthwhile, do a point, counterpoint article where an interesting collaborative piece could give all sides of the story that would help patients make the best decision for what’s right for them.

      • http://twitter.com/PedInsider Roy Benaroch MD

        Why don’t you share with us some links to some of the research you’ve done? If you (or any of the other chiropractors who seem so enraged at my post) would provide some solid examples of pediatric study, that would be a relevant and compelling response to my post.

    • christopherries

      This is only because our profession is restricted by constraints of time and money. We as a profession are not sponsored by Phizer or Abott pharma. Without the big funding for big research we will just have to rely on our patients coming back because it WORKS. that should be enough. We suceed where medicine has failed. People are demanding to be cared for and not pushed medicines that rarely help their conditions.

  • Mike C.

    I think you should look in the mirror, because you might be projecting pretty heavily in your response.

    • Jay Greenstein, DC

      Mike, folks who feel persecuted can either sit back and take it or speak out. With all due respect, take your psychobabble somewhere else.

      • Mike C.

        Merely an observation, based upon your child-like behavior which reminds me of the age old playground defense, “I’m right, your wrong, “.

        Of course this may all simply be due to your own insecurities since you feel “persecuted”. In all honestly I don’t know why would you feel persecuted by someone who really has no influence on your life. This child-like behavior is further Illustrated by your commitment to tell people they are wrong while making assumptions about their personality based upon one article and perhaps a few comments.

        In the future, adult-like behavior would be to simply point out the specific flaws in a statement/ article, present sound logic, or even better, evidence to the contrary, and move on. This would be “speaking out’ in a constructive manner and demonstrates a level of professionalism I would want from my chiropractor.

  • Molly_Rn

    Why would anyone take their child or themselves to a quack?

  • http://www.facebook.com/tonyebeldc Anthony J. Ebel

    Dr. Benaroch,

    I am a trained and certified pediatric chiropractor, and actually run one of the largest pediatric clinics in the world, with an expertise in the areas of spectrum-related disorders and neuro-development. We also have a large general family/peds side of our practice.

    As such, I’m thinking right now of what approach I’m going to take with this reply… and that is I actually in many ways agree with you, yet also feel that there are too many discussion points left out in order to come to the conclusions you do. But, I understand that as it is a blog post so you can’t nearly cover it all (just as I won’t be able to in this reply)… and also, not being in the field directly yourself is limiting… just as of course mine would be in critiquing your profession (which I’ve certainly done many times… see: antibiotic use for ear infections).

    My first response honestly is this: Damn it sucks that we don’t have more research to show the world exactly how great of results we really do get with pediatric chiropractic care.

    The results I get in my clinic absolutely defy all “scientific” understanding to most of the world, especially your profession and the general scientific community in general… but this is actually not because there is not pure science behind what we do, it’s just that: 1) It’s never been explained appropriately, and 2) You guys ask far different questions than we do, looking for far different conclusions.

    A major issue here is simple: funding and time. Chiropractic simply has no funding for research, and very, very few people in our profession actually interested in doing it. Those that have done it or do it continue to look at things we already know about… back pain and such. Back pain is a real problem and I’m glad we have folks who are good at taking care of that. But… autism, ADHD, allergies, asthma, and such are also real hugely exploding problems that NO ONE is really doing anything about.

    The time thing is the biggest frustration for me… I say this with absolute certainty and no reason to benefit from lying… we routinely (multiple times per day) resolve fully issues such as colic, ear infections, asthma, and allergies… and also make massive impact on ADHD, anxiety, and autism… as well as seizures… often seeing full resolution of those issues as well. However, I am so damn busy doing just that that I’ve produced ZERO research in 5 years of running one of the largest and most successful peds clinics in the world. That is not meant to be an excuse, it is just reality. I literally just finished a consult with a set of parents of an ADHD child starting care and explained the same thing to them… about how I need to simply have an intern spend months going through my records and producing research.

    But I think the biggest thing that is missing from full explanation of your post is what “evidence-based” and “research” really is. RCTs and such are not the only version of research that should be relied on. I know you are aware of an in agreement with this from other discussion below, but it is important.
    What I rely on almost solely is my clinical experience. Yes, I was taught alot in my education and by my mentors in relation to what I do… but the vast majority of it is from 5 years of getting incredible results.
    Now what I’ve done is actually formulated my clinical experience into a number of hypothesis, which I have then set about testing and reproducing in practice… which are now to the point a very exact systems of analysis, protocols, and procedures that I (and my other docs) follow like clockwork… and now we are seeing very reproducable results, and we apply them daily.
    Right now I’m in the final stages of creating a training program for pediatric chiropractic which will cover all of this, from the science to the application to the protocols… and with that I hope to expand this practice, which of course will expand our understanding and results… which then should lead to more research and evidence.
    Lastly, I absolutely one day will be building a large teaching and research clinic alongside my practice… where we will take on recent graduates and put them into a clinical internship/residency for 6-18 months where they will not only get clinical experience, but where we can work as a team to produce additional types of research… the types that you, your colleagues, and other science-type folks are looking for.
    So my concluding thoughts (yes, I’m long-typed) are that you are both right and wrong… but in the end, I completely understand your writings and conclusions given how you were trained and taught to think and practice.
    And the last thing I must add is this: Please somehow work with your colleagues to take on the “medical chiropractors” and get them OUT of our profession. We can both surely agree that our children need something that is going to give them far greater health… if you guys and more vaccines and antibiotics and cow’s milk were the answer… we’d not be in the position we are right now.
    What people need, and are currently seeking out by the droves (and paying cash for) are the exact opposites of those things… they want things that are different, unique… and things that actually work.
    There is that group of my “colleagues” who want to grow up to be just like you one day… a “real doctor” and they admonish the subluxation as if it is “historical” rather than scientific. It’s not their fault, their schools just didn’t teach them the science (neither did mine) behind it, and they haven’t stepped up and learned it themselves… so they “straw man” it and try and take it down.
    The science behind the subluxation is extremly strong, and extremely easy to understand, despite it’s complexity. I’d be more than happy to get on the phone with you one day and walk you through it step by step, or even do a presentation for you and your colleagues anytime on it… as I’ve done that often. I actually am working on an NIH grant with some neurologists and others from Rush to look at our work with seizures, so once they learn… they want more!

    • Molly_Rn

      So you must
      believe in miracles too. Subluxation is a fantasy provided by chiropractors to get money from people. If someone’s research said putting a bean up their nose and leaving it there for a week would alter their deviated septum I guess by your theory of “What I rely on almost solely is my clinical
      experience” it would be beneficial and should be practiced. Your ego is bigger than your knowledge which is quite small. Just because something has been done for a long time, like say burning witches or putting them to the rack, doesn’t make it good.

      • http://www.facebook.com/tonyebeldc Anthony J. Ebel

        Unfortunately it is clear that because you’re initials are RN, and mine are DC… that you have more “knowledge” than me.

        Since you have called subluxation “fantasy” – please go ahead and display your knowledge and use it to explain your point, scientifically.

        If you are able to prove to me that the fact that abnormal alignment and therefore mobility/motion of a joint (dys-kinesia) does NOT indeed lead to dysafferentation (decreased proprioception and increased nociception) reaching the dorsal horn of the cord, brainstem, cerebellum (esp. vermis)… which is then relayed to higher brain centers such as the amygdala, hypoothalamus, hippocampus, and prefrontal cortex…. which then leads to dys-autonomia (most often sustained sympathetic shift then affecting the HPA axis and neuro-endocrine response) and dys-ponesis… then you win.

        So since you have this proof of it being “fantasy” and I have instead multiple peer-reviewed studies, including fMRI, EEG, and other findings to prove not just the existence of subluxation but also it’s neurophysiological effects that are detrimental to health and function… I’d love to see it or hear it.

        What I rely on for my care protocols and procedures are mostly on clinical experience… subluxation was proved long ago, and is the basis of all my care.

        What do you base your care on? Simply things you were taught in RN school I’d imagine.

        Have you done the research on ALL things you apply and provide for your patients each and every day? You know exactly how each drug and procedure affects the patients physiology.

        If you do great… Because I know exactly how what each thing I do does.

        • http://www.facebook.com/tonyebeldc Anthony J. Ebel

          Hopefully one day you’ll learn than “RN” does not stand for “smarter than everyone else, especially chiropractors”

          • Molly_Rn

            Never thought they did mean smarter than everyone else, but I do think smarter than chiropractors and snake oil sales men.

          • Craig Andresen

            Molly Rn I will refrain from insulting you but I think you are foolish to be so convinced about something that you have no experience or training in. You know some physicians who bad mouth something that they also have no training or experience in. I am a Chiropractor and I see about 250 people a week in my clinic. I do not push subluxation, I just get people well. They would not be coming back and referring their friends and family if it didn’t help. Chiropractic is the fastest growing and second largest primary health care profession.

          • Molly_Rn

            Sad to see so many people sucked in by quackery.

        • Molly_Rn

          I know many physicians who can know that subluxation is bunk. I went to the university for
          my education and I learned about science and how you actually prove causation not coincidental. I still say BUNK.

          • http://www.facebook.com/cory.thiele.7 Cory Thiele

            Molly, at least you thoroughly “de-bunked” Dr. Ebel’s explanation of the neurology of the spinal issues that Chiropractors address daily with your profound knowledge. We will keep improving the health, vitality, and lives of our patients while you hand out meds and clean up bedpans.

          • Molly_Rn

            You are a real class act. I feel sorry for your patients. They need to find a real physician not a quack. Oh and by the way I work in ICU/CCU with all those funky machines and invasive lines so your putdown was humerous. I hope the next time you are in the hospital the nurse forgets to get you a bedpan.

  • http://www.facebook.com/randy.hammett Randy Hammett

    An M.D. Commemting on Chiropractic care? Get real! Where and when was your education on the science of chiropractic? Research? Really shall we blog about the less than 6% of medical procedures that are thoroughly studied? Come on Doctor, you stick to the field you were taught in and I will stay in mine. Talk about the pot calling the kettle black!

    • http://twitter.com/PedInsider Roy Benaroch MD

      My essay was entirely based on reviews of the chiropractic literature, written by chiropractors, published in chiropractic journals. Would you like to address my specific point, that very little chiropractic research is performed on children?

      • Robert Zoboski, DC

        I have been a practicing chiropractor for 21 years. My favorite part of the day is seeing my patients. You see, there is no “washout” period or titrating involved; the result of treatment can be immediate and dramatic. Chiropractic care, namely spinal manipulative therapy, is a very powerful therapeutic intervention when used in the appropriate setting. My profession is certainly not short of anecdotal findings; yet there are very few of my colleagues that are actively engaged in contributing to the literature.

        When I look back through the retrospectroscope to my first week of practice, I recall making an appointment to visit the gynecologist across the hall to enlighten him on the benefits of chiropractic care and to have him refer his patients to me. He had been in practice for over 30 years and was well respected in the community. Besides friendly introductions, I didn’t say a word; I listened. In sum, his advice to me was to engage in scientific research and to publish my findings; he thought the chiropractic profession didn’t do enough in this regard. A second piece of advice was, “don’t do anything stupid”. He said that if I followed these two principles, that everything would be all right

        Since then I have learned that academic and professional integrity carries with it elements of honesty, trust, fairness, respect, and responsibility. I’ve learned the hierarchy of academic research regarding meta-analysis, best evidence, RCT’s, case control studies and the like. I’ve learned that publishing case reports, albeit low in the research totem pole, is well within the domain for us, as solo practitioners, to actively engage in. My first paper, “Minor ice hockey injuries; a paradigm for safety” was eviscerated by the editorial board of The American Journal of Sports Medicine secondary to methodological problems (descriptive, retrospective). I subsequently spent two years on the shoulder and produced a wonderfully layered chapter only to have the two main contributors breach the publishing contract wherein all extra-spinal regions/chapters were cut. It became obvious to me that I needed more training. I completed a fellowship in clinical orthopedics and later a Masters in Advanced Clinical Practice and I’m happy to report that I have finally contributed to the greater body of knowledge by publishing a case report; I have a second in the oven. I often wonder about the impact the chiropractic profession could have regarding the health of our nation if even 10% of all practicing chiropractors would continue their training through the readily available diplomate and other post professional programs and to actively engage in publishing their findings. However, case reports require great time and effort as well as a commitment to stay current with the literature; not an easy task when you have a family and most reimbursement from third-party payers is woefully inadequate and continues to decline. As the provider relations medical director for one of the “Big six” insurance company states, “The days of independent practice are over”. So now what?

        No individual practitioner, on either side of the fence, has all the answers; the problem appears to be the fence. Professional collaboration is the answer for optimal patient care, at least as I see it; after all, it’s about providing the absolute best care for our patients, isn’t it? Collaboration requires communication. Sadly, when the profession of chiropractic continues to remain divided, there is no hope for cultural authority through uniform communication and therefore, the fence remains. Maybe the answer will come with a modern day Abraham Flexner for the chiropractic profession. As Einstein stated, “Science without religion is lame, religion without science is blind”.

        • http://twitter.com/PedInsider Roy Benaroch MD

          Modern medicine, and modern medical education, certainly owes a great deal to Abraham Flexner. He gave a huge push towards science-based education, and changed the profession. Such a figure could certainly similarly transform chiropractic, if the profession would embrace the change.

          I’m curious, Dr. Zoboski: among the rank-and-file, practicing chiropractors, where do you think the split lies between the straight, Palmer/subluxation-focused practitioners, versus the more “science-minded” types?

          • christopherries

            Does it really matter? I have read these posts only to think to myself… Do these people have lives? Get a life really. Go hug your wife. Plant a tree. watch your children playing and doing what we were all meant to do. Quit focusing on the little things which have no meaning. Learn to love and help those with good intentions and forget all the damn research. In the end the world will be a better place without all of your science. Sometimes the science is the problem!

  • Dolly Garnecki

    Misguided posts like this make me shudder. With such a cursory view of the research (exactly which key words did you use in your search?) did you fail to reach any of the research published in peer-reivewed Chiropractic and Osteopathy on scoliosis. What about the thousands of articles published in peer-reviewed J of Clin Chiro Peds with case studies and research on pediatric cases? Oh wait…your post was biased in it’s title and research presumption before you began.

    Actually, why don’t you do a review of the literature on the traditional medical treatment for scoliosis. Watch and wait…because if we watch and wait, that scoliosis will just turn around on it’s own (NEVER). Then, there’s bracing. Tons of literature pointing to the emotional and psychological scarring…and of course, the fact that rigid bracing does not, in fact, halt or reverse scoliosis. Wow, that’s a bummer. Then, there’s scoliosis surgery. None of the surgery research indicates that there is an improvement on cardiopulmonary function. Rather, the risk of metal implants is corrosion, breakage, subsequent surgeries since scoliosis progresses at a rate of 2.4 degrees per year…oh, and then, there’s the risk of death. Let’s not forget the emotional scarring of a giant scar the length of a patient’s spine and across the iliac crest as a result of surgery.

    Gosh, if you’re going to bash chiropractic with a glimpse at 1 study (and there are several on the benefits of chiropractic and physiotherapy and scoliosis correction), then, give equal weight to the hundreds of studies that are ineffective with the traditional medical model.

    But, I urge you to spend more than 2 minutes with a petty scan on pubmed…actually spend some time trying other key words or READING chiropractic journals before you hastily pen an incomplete post that doesn’t support the title. You’re taking on chiropractic, pediatrics, and scoliosis within a scant few paragraphs. I’d say, you’re biting off more than you can chew.

    • http://twitter.com/PedInsider Roy Benaroch MD

      Again, and I apologize for being a bit of a broken record here: my post is based on three reviews of the chiropractic literature on pediatric patients. The reviews were performed by chiropractors and published in chiropractic journals, and the links are clearly provided in the original post. If you feel that these authors neglected any studies, I’d appreciate your providing a link.

      Lots of affronted feelings here in the comments. Very little actual facts to argue against my conclusion: there is an appalling lack of study of chiropractic care on children.

      • Molly_Rn

        You should request actual studies, not garbage “studies” that are designed to show good results.

        • http://twitter.com/PedInsider Roy Benaroch MD

          Molly, at this point I’ll look at anything that actually responds to my post.

          • Molly_Rn

            I totally agree with your post. But anything that casts doubt on chiropractic brings up a barrage of defense of all things chiropractic. Sorry, but I am sick and tired of pseudoscience. I think trusting a chiropractor rather than a pediatrician is dangerous thinking. It would be interesting to have actual conclusive proof of the existance of subluxation and especially in children and that it actually causes (not conincidental) pain, illness or a physical problem in children.

      • N N

        Always love your columns Dr. Benaroch. Would be nice if levelheaded people like yourself headed the ABIM. A man can dream.

    • Mike C.

      I too would appreciate links to these journal articles supporting chiropractic care in children for scoliosis which you maintain exist.

    • Vince Smith

      when are people going to understand that double-blinded randomized controlled trials are research and case studies are story time?

  • http://twitter.com/CPTsopiens Daniel Mattson

    Just think about how many medical interventions over the years were not evidence based by strong levels of evidence. Dr. Benaroch is not providing an alternative, so his opinion is not real helpful. Lets see, do nothing but observe or try something at reasonable cost that might help? That’s a no brainer and the doc would be wise to do whatever he can to prevent the worsening of scoliosis in his own children.

    Oh, and Dr. Stephens, rattle snake venom (eptifibatied) would be quite beneficial if you were having an acute coronary syndrome.

    • http://twitter.com/PedInsider Roy Benaroch MD

      So, you’re saying it’s better to do something– even if you don’t know it works, even if you don’t know its dangers– than do nothing, even for a condition that may not need any therapy at all?

      I thought it was the greedy doctors pushing the pills people don’t need. I’ve got this situation all backwards.

  • http://twitter.com/CPTsopiens Daniel Mattson

    Just think about how many medical interventions over the years were not evidence based by strong levels of evidence. Dr. Benaroch is not providing an alternative, so his opinion is not real helpful. Lets see, do nothing but observe or try something at reasonable cost hat might help? That’s a no brainer and the doc would be wise to do whatever he can to prevent the worsening of scoliosis in his own children.

    Oh, and Dr. Stephens, rattle snake venom (eptifibatied) would be quite beneficial if you were having an acute coronary syndrome.

  • http://twitter.com/CPTsopiens Daniel Mattson

    Yes, I see the point of your article,but criticizing the state of the science of one discipline without offering better science from your discipline is being critical, and not helpful to the matter at hand, treating/preventing scoliosis. My kids have scoliosis as does my wife and just sitting back and observing is not treatment. I have read many articles including NEJM and most are based on observation until a critical point. I’m not afraid to try something not harmful/possibly beneficial for a reasonable cost, as are most consumers. Much of healthcare is based on such analysis of risk/benefit.

    • http://twitter.com/PedInsider Roy Benaroch MD

      Sitting back and observing is often the BEST treatment for scoliosis, at least for the patient. Most scoliosis remains well within the range of what will never cause any symptoms for the patient. There are good guidelines and prospective studies to support this, as I’ve documented above.

      Absent a single, 6-patient feasibility study, there is no support for any chiropractic treatment for childhood or adolescent scoliosis. There is also miniscule support for chiropractic treatment of any pediatric condition. I continue to look forward to any comment that refutes this in a meaningful, evidence-based way.

  • Shelly Jones

    First of all…a parent should be very careful before they take their child to ANY doctor. When you see the CDC statistics from antiobiotic abuse, vaccine reactions and prescription medication overdoses, it should be your topic and focus on the blatant mal-practice of your fellow medical physicians. Compare that to the statistics, insurance risk actuarials for chiropractic and pediatric chiropractic physicians and it doesn’t even begin to compare. I can’t speak to your intention, but as it appears in print your information is lacking, misguided, and uninformed in the reality of health care practices. Yes, I am a parent and a chiropractor so I speak from experience from having my children under chiropractic care their entire lives with the occassional need for medical intervention and from the experience of having cared for infants and children throughout my nearly 30 years in practice.

  • Meagan Leahy DC

    We garner more respect from our patients for the simple fact that most of us form actual relationships with them, provide them great services at a reasonable, and take the time to educate them on actual “health” and not just provide them a drug for the rest of their life. I am not saying every doctor is the same as there are mds that do that and some chiropractors that don’t, but that is the feedback by the majority of patients in my office regarding their PCP or surveys that I have ever seen.

    The truth of the matter is that the current system of “healthcare” in the United States has statistically make us one of the worst nations in health as ranked by WHO. Patients are tired of taking more pills and want to actually feel better and will find people who can help them the natural way.

    In regards to pediatric and even adult care, yes, there needs to be more research ( and more EBM is occurring) but the truth as my colleague pointed out is that we simple lack the funding for most of the big studies. If you someone could talk to Merck and Co and get them or the government to help us out, that’d be great. Considering that they won’t make money of our findings, my guess is that we, as a profession, will have to continue they way we always have-with great results, reliably repeated for another 100+ years allowing us to grow by referral as we always have. I have many patients who gladly and willingly pay me money for their care and their families because they value the service and the care. People don’t stay around for things that aren’t helping them or work, they are smarter than that.

    Lastly, in regards to EBM-follow your own rules MDs! You prescribe things that have had limited amounts of studies with often only the positive findings provided presenting a very biased opinion for those “researching” on-line, etc who can’t find anything bad. The “research” is often done by parties with a vested interest in the success of the research financially.

    I am a proud chiropractor who is certified in not only Pediatric care through the ICPA (check them out) but also a CBP (Chiropractic Biophysics) practitioner-which is the most researched of any chiropractic technique published in magazines such as Spine. They have information on scoliosis and yes, even some on pediatric.

    • http://twitter.com/PedInsider Roy Benaroch MD

      Why don’t you post links to some of these articles you mentioned in your last paragraph– the ones in support of chiropractic care of scoliosis for children?

      • Meagan Leahy DC

        It was challenging to find a link to post and make it simple for you and the users and as it is not my research, I did not feel that I should post items that I wasn’t sure they had “released yet”. Dr. Joe Ferrantelli, DC would be an excellent research and the best person to contact for research, etc. drjoe@idealspine.com
        I am currently working on a 12 y/o wanting to avoid surgery and you have inspired me to take the time to write her story and share her results.

  • http://twitter.com/PedInsider Roy Benaroch MD

    What “evils of chiropractic” did I mention? So much bombast, smoke and mirrors in these responses. I made a simple point: chiropractic treatment of children has not undergone study. Would you like to respond to what I actually said?

  • http://twitter.com/PedInsider Roy Benaroch MD

    I don’t know if the 20% figure is correct, but assuming it is: that only refers to FDA approval, which is applied for when a drug is first marketed. Further studies done from that point forward don’t change labeling unless the FDA is petitioned by the manufacturer, which is seldom done. All of the medicines I use are tested in children. Can you say the same for any chiropractic therapy? (note how I am trying to steer this back to the point of what I wrote, which so far is being completely disregarded by you. Perhaps you’d like to make some kind of relevant response.)

  • http://twitter.com/PedInsider Roy Benaroch MD

    OK, I think all of us can agree that this post gets the freak award for meaningless prose. Take a bow.

  • http://twitter.com/PedInsider Roy Benaroch MD

    Yes, that would be a study of ADULT scoliosis. You can even tell by the title. You may not have noticed, but my entire post and all of my comments have been about the lack of study of chiropractic therapy in children.

  • Frank M. Painter, D.C.

    Most interesting. The papers you reviewed all noted that the quality and quantity of our research is sparse. Rather than looking down your nose at the volume, you might ask WHY there is so little. It’s easy for an Ivory Tower Geek to ignore the fact that Organized Medicine spent decades trying to destroy my profession, threatening their own ranks with loss of hospital privileges IF they participated in research with us, taught at our schools, or even accepted referrals from my profession. [1] Finally, they (along with 20 other named medical entities) were found guilty of anti=trust activities against us…twice!

    In that toxic atmosphere of suppression, its little wonder that our research infrastructure was stunted…after all, what research we do have was 100% paid for by our own profession, an unparalleled situation in biomedical research. In fact, not one chiropractic researcher received one thin dime of research money from the NIH until 1998. Since that time, there has been a consistent flow of high-quality research and studies published, mostly relating to low back, headache and anatomical studies of the impact of joint fixation. [2, 3, 4]

    Our Pediatrics Section [5] contains a cross-section of studies reviewing the benefits of chiropractic care for children. Is it exhaustive? No.

    There are 2 points worth considering:

    1. Chiropractic care for headache and low back pain is highly effective AND cost-effective [6] compared to medical management for identical complaints. It also garners MUCH higher satisfaction ratings, compared to medical treatment for identical complaints. [7]

    2. Chiropractic is vastly safer than medical management, which is often recommendations of using NSAIDs, muscle relaxants, or PT. In fact, a recent study by independent researchers found that you are TWICE as likely to become disables IF you receive your care from a PT, rather than a chiropractor, and 60& more likely to become disables IF you see an MD, rather than a chiropractor. [8]

    I do not question your genuine concern for the safety of children. I do question however, your knowledge about chiropractic, our history, philosophy, safety, and effectiveness. I invite you to review more than these few articles you mention (see above) and open your eyes and mind to chiropractic as an alternative approach to the usual drugs and surgery approach of conventional medicine. Believe me, medicine’s track record, and their body of research is equally lacking where it matters, in the treatment of what chiropractors see and treat on a daily basis.

    ————————————————————————–

    REFERENCES:

    1. The Chiropractic Antitrust Suit: Wilk, et al vs. the AMA, et al
    http://www.chiro.org/Wilk/

    2. Low Back Pain and Chiropractic
    http://www.chiro.org/LINKS/lowback.shtml

    3. Headache and Chiropractic
    http://www.chiro.org/LINKS/headache.shtml

    4.What is The Chiropractic Subluxation?
    http://www.chiro.org/LINKS/subluxation.shtml

    5. Chiropractic Pediatrics Section
    http://www.chiro.org/pediatrics/

    6. The Cost-Effectiveness of Chiropractic
    http://www.chiro.org/LINKS/Cost_Effectiveness.shtml

    7. Patient Satisfaction With Chiropractic
    http://www.chiro.org/LINKS/Patient_Satisfaction.shtml

    8. Health Maintenance Care in Work-Related Low Back Pain and Its Association With Disability Recurrence
    Journal of Occupational and Environmental Medicine 2011 (Apr); 53 (4): 396–404
    http://www.chiro.org/LINKS/ABSTRACTS/Health_Maintenance_Care_in_Work-Related.shtml