NHS and alternative therapies for back pain

kipple

This is taken from todays UK Independent newspaper.

http://www.independent.co.uk/life-style/health-and-families/health-news/nhs-pins-its-hopes-for-treating-back-pain-on-acupuncture-1691215.html

Tens of millions of pounds are being wasted by the NHS on useless treatments for back pain, money that should be diverted to alternative therapies such as acupuncture and spinal manipulation, a health service watchdog says today.

From among 200 treatments and devices claimed to help a bad back, the National Institute for Clinical Excellence (Nice) has passed judgement on what works and what doesn't. X-rays, ultrasound and steroid injections are out and osteopathy, chiropractic and "needling" are in, it says.

I have noticed that this forum is generally anti alternative therapies which made me hesitate before posting as I dont want to get attacked but I wonder if this is a sign that things are changing. I know doctors who would have a lot of resistance sending a patient to an osteopath never mind to a chiropractor. I know acupuncture is shown to help relieve the symptoms of back pain but does it help with what ever the root cause of the pain is?

As an alternative therapist (not one of the ones mentioned above) I welcome an expansion of the tool available to GPs for dealing with back pain and I would like to see a situation where the GP has the information and knowledge to refer the patient to the appropriate alternative therapist.

The National Institute for Clinical Excellence is a great sounding title but does any body here have opinions on how reliable this group is.

tallaght01

kipple wrote: »

I would like to see a situation where the GP has the information and knowledge to refer the patient to the appropriate alternative therapist.

.

It's this bit that stumps us, mostly. What is the appropriate therapist? Ans what are the appropriate conditions to refer for? And where is the evidence?

The forum is definitely not ant alternative treatments. We've strongly resisted calls for alt medicine discussion to be banned.

But what we won't be tolerating anymore is people coming on claiming a specific therapy works, without providing decent evidence. Anyone who can do that (and there is some evidence out there, especially for acupuncture) is more than welcome here.

I was at my 2nd alternative therapy "lecture" in as many weeks yesterday. Yet again, not a shred of evidence. I went there with an open mind, hoping to learn, but instead I got the worst, most patronising lecture I've ever been to. I firmly believe some of these things work. BUt until their practitioners take some responsibility for producing a it of evidence, then you simply can't blame us for being sceptical.

2Scoops

Proven therapies have never found trouble here. NICE and WHO agree. Unproven therapies are met with skepticism (chiropractic for asthma, anyone?).

samson09 wrote:

Acupuncture in this case may then be used to send healing energy or chi to the affected area where it will reduce inflammation and speed up the healing process.

Can you quantify healing energy or chi? If you can't, how do you know it's there? I'm not saying acupuncture cannot work in this context, but there is simply no evidence to suggest chi is the mechanism, or even that it exists.

mumof3angels

I was in a car crash 8 yrs ago and I took all the usual medicine known that the doctors give out and nothing worked. I then was recommend by my DOCTOR to try a chiropractor and they did a brilliant job. I was finnally able to enjoy things again.
I am not say that it works for everyone but it did work for me.
I have also tried the acupuncture for sinus and it did not work
so as i said something work some dont, buts everone to ther own

2Scoops

samson09 wrote: »

And dont tell me about natural health generating billions a year, how much do you think the average acupuncturists, reiki practitioner and homeopathist make? Enough to fund a double blind, placebo controlled clinical trial that would most likely cost hundreds of thousands if not millions for something they already know works? Only drug companies can afford to do this, as they know that once the product is pushed through, it'll generate millions for them.

The majority of medical research is not funded by Big Pharma, but by state bodies or independent organizations. This money is freely available to to any researcher who applies.

samson09 wrote: »

Oh, and you dont believe taht something called chi exists?

Ok, I'll bite: what does it look like?

2Scoops

mumof3angels wrote: »

I was in a car crash 8 yrs ago and I took all the usual medicine known that the doctors give out and nothing worked. I then was recommend by my DOCTOR to try a chiropractor and they did a brilliant job.

That's because DOCTORS freely recognize the benefits of chiropractic in certain contexts where it has proven efficacy. Simple, really.

tallaght01

Samson09, I'll be straight with you. I don't think all CAM is nonsense. But i think you talk nonsense.

That would be fair enough if you were just a bit naive. If you bought the argument that RCTs cannot happen in CAM, even though I've read several of them! Even if you were so self indulgent as to believe we don't need evidence to fund something because you "know" it works. Even if you weren't aware of the amount of disease cured/removed/prevented every day by medical staff who are "useless" at treating "The condition". Even if you weren't smart enough to see that you using treatment of "the condition" as your benchmark of effectiveness for doctors directly contradicts your holistic ideals......then you'd be just not very well educated, and pretty harmless.

But, it's pretty obvious you do a lot of the above to get a rise out of people. That's fine. But I'm not going to get into a mickey measuring competition with you here. If you start to post evidenced based, non-antagonistic thoughts, then fine. But the next piece of nonsense you post is getting you a ban.

1 week first. Then permanent.

kipple

It's this bit that stumps us, mostly. What is the appropriate therapist? Ans what are the appropriate conditions to refer for? And where is the evidence?

Do doctors have a responsibility to keep up to date with the conditions that they are treating on a day to day basis?

A medical group in the UK has made specific suggestions for treatment of back pain. They must get their evidence from somewhere?

I have seen papers and reports with evidence for Acupuncture and Rolfing.

There is evidence that cortisone injections into facet joint is NO more effective than saline injections. The opening talker of the 3rd World Congress of Low Back and Pelvic Pain stated that many recent studies that show little or no correlation between disk anomalies and backpain. Yet this is the model still used by many doctors.

NOTE: I do NOT have access to medical journals and databases which I would love to have. This cost lots of money. So yes I have not read these papers and more importantly do not see the possible evidence disputing the claims. However I assume Doctors do have access to these databases and have a responsibility to stay informed. Also why is this information not freely available? So doctors have access to an overwhelming amount of information that the public can not access. It is your responsibility to read this and then tell us the public what is the best course of action?

What papers have you read on low back pain? Do you dispute the findings of the NICE group? Do finding show that acupuncture is better for acute or chronic pain? What is the causal relationship between disk anomalies and back pain? If evidence shows the meridian system does not exist what other mechanisms MAY explain acupuncture apart from the placebo effect? There must be tons of evidence out there directly aimed at and written for doctors.

I was at my 2nd alternative therapy "lecture" in as many weeks yesterday. Yet again, not a shred of evidence. I went there with an open mind, hoping to learn, but instead I got the worst, most patronising lecture I've ever been to. I firmly believe some of these things work. BUt until their practitioners take some responsibility for producing a it of evidence, then you simply can't blame us for being sceptical.

As a Rolfer I am proud that the Rolf Institute sponsored and was the main push behind getting the Fascial Research Congress off the ground.

Does this conference look more like something that would start to give insights and evidence into the scientific basis for manual therapies?
http://www.fasciacongress.org/

DrIndy

although i am in favour of debates on this forum - deliberately antagonising ones will be curtailed from now on and protagonists will be banned.

Please be mindful of this Samson09. If you want a hand or tips on how to dissect a paper - there are many scientific minds here who can help, it may help you when you present your view of the debate (which on principle is welcome and you have been a frequent contributor).

Myself and Tallaght01 want to gently raise the standard of the forum and stop flaming.

Prime Mover

As usual a thread about CAM is hijacked by a troll......

Anyway to get back to the original post, I think this is really lazy journalism. It's all generalisations about "back pain" and "bad backs". If you read the origninal NICE publication http://guidance.nice.org.uk/CG88/NiceGuidance/pdf/English it says

"Non-specific low back pain is tension, soreness and/or stiffness in the lower
back region for which it is not possible to identify a specific cause of the pain."

"Specific causes of low back pain (not covered in this guideline)
Malignancy
Infection
Fracture
Ankylosing spondylitis and other inflammatory disorders
The management of the following conditions is not covered by this guideline:
• radicular pain resulting from nerve root compression
• cauda equina syndrome (this should be treated as a surgical emergency
requiring immediate referral)."

So I basically read this as NICE asking doctors to stop wasting a load of money on X-rays, MRIs and drugs that are not required. Their condition is probably somethign to do with lack of exercise, poor posture or psychological stress in which case giving them an exercise program, some massage and some acupuncture will probably help.

Do I believe acupuncture is healing them by magical Chi forces, no, but if the placebo effect works for them it's better than them gobbling NSAIDs and screwing up their stomach and kidneys.

tallaght01

I think we treat lower back pain pretty poorly. Does that mean we should just accept any alternative that comes along? Of course not.

I don't really have a lot of patients with lower back pain. But I'm not going to able to go martial arts training for the next 2 months I reckon, because I've totally mongled my back. I don't hold out much hope for conventional medicine in the treatment of this condition. Most doctors would agree with that.

BUt at least we can accept that. If you want to talk about correlation between disk anomalies on scan and pain, then talk to the chiropracters. I have never ever met a chiropracter who could give me the measurement, or the specific anatomical anomaly used when diagnosing "misalignment of the spine".

My understanding of the role of MRI/xray in conventional medicine, is to make sure there's nothing nasty going on, or there isn't any disc herniation. Lumbar spine xrays are the radiation equivalent of a gazillion CXRs, and I don't remmeber ever ordering one off my own bat.

What's a rolfer, by the way?

Spear

tallaght01 wrote: »

What's a rolfer, by the way?

http://en.wikipedia.org/wiki/Rolfing

Rolfing is the commonly used name for the system of Structural Integration soft tissue manipulation founded by Ida Pauline Rolf in the 1950s. The terms Rolfing and Rolfer are trademarks of The Rolf Institute of Structural Integration.

A 2004 review of Rolfing found that "there is no evidence-based literature to support Rolfing in any specific disease group".

tallaght01

So, a rolfer, who is selling their treatment, should have access to medical journals,or at least rolfing evidence?

Spear wrote: »

http://en.wikipedia.org/wiki/Rolfing

Rolfing is the commonly used name for the system of Structural Integration soft tissue manipulation founded by Ida Pauline Rolf in the 1950s. The terms Rolfing and Rolfer are trademarks of The Rolf Institute of Structural Integration.

A 2004 review of Rolfing found that "there is no evidence-based literature to support Rolfing in any specific disease group".

kipple

Rolfing
http://rolfing.org

As this is the Biology forum here are some papers (theory/biology based + clinical)

http://www.somatics.de/FascialPlasticity/Part1.pdf
http://www.somatics.de/FascialPlasticity/Part2.pdf
http://www.fasciaresearch.com/James/James2009.pdf


As for the paper quoted from wikipedia, I don't have access to it, what journal was that published in? That is just really lazy. At least read the evidence before quoting it here.

the guidelines state:

"Evidence" should take the form of some kind of scientific investigation. Specifically, websites and opinion are not evidence.

A little bit of evenness would be good in applying the rules, for example.

Do I believe acupuncture is healing them by magical Chi forces, no, but if the placebo effect works for them it's better than them gobbling NSAIDs and screwing up their stomach and kidneys.

The implication here is that acupuncture works for back pain and that there is evidence to support this. If you claim that placebo effect is the main mechanism behind acupuncture produce the evidence. To claim that the placebo effect is the main mechanism behind acupuncture is easy to do and shows no curiosity about the deeper biological effects of needling. This is the biology forum after all. What about discussing the first two papers I have linked?

I am feeling a little out gunned here.

tallaght01

kipple wrote: »

Rolfing
http://rolfing.org

As this is the Biology forum here are some papers (theory/biology based + clinical)

http://www.somatics.de/FascialPlasticity/Part1.pdf
http://www.somatics.de/FascialPlasticity/Part2.pdf
http://www.fasciaresearch.com/James/James2009.pdf

.

Now we're getting somewhere.

So, you have some papers. Don't just post links. Discuss them. Tell us a bit about them, why they're good or bad evidence. Are the results applicable to a wide range of patients, or a specific group.

Roll with it, and I guarantee you people will engage with you. If you do this, DrIndy and I will make sure you are treated with nothing but civility and respect on this forum.

Dr Galen

kipple wrote: »

Rolfing
http://rolfing.org

As this is the Biology forum here are some papers (theory/biology based + clinical)

http://www.somatics.de/FascialPlasticity/Part1.pdf
http://www.somatics.de/FascialPlasticity/Part2.pdf
http://www.fasciaresearch.com/James/James2009.pdf


As for the paper quoted from wikipedia, I don't have access to it, what journal was that published in? That is just really lazy. At least read the evidence before quoting it here.

the guidelines state:


A little bit of evenness would be good in applying the rules, for example.



The implication here is that acupuncture works for back pain and that there is evidence to support this. If you claim that placebo effect is the main mechanism behind acupuncture produce the evidence. To claim that the placebo effect is the main mechanism behind acupuncture is easy to do and shows no curiosity about the deeper biological effects of needling. This is the biology forum after all. What about discussing the first two papers I have linked?

I am feeling a little out gunned here.

Kipple, I haven't read fully those papers, I will studies later when I get a chance, but this is exactly what everyone is talking about here! You've made an attempt to convince by linking to actual papers. Sure they're not double blinded RCT's but at least they are a step in the right direction. In fairness it might be pretty hard to double blind a lot of Alt Medicince studies purely from a practical point of view.

The findings look interesting and the authors point to the fact that further work with larger sample groups is needed which is true of a lot of work done, on both Alt and Conventional medicine.

2Scoops

406C wrote: »

Not really since we know steroids say work with croup yet the most often quoted theory of action i.e. combating the inflammatory response can’t be the only factor if indeed any factor since the rapid response seen in several studies suggests there is another mechanism at work and so it essentially has an unproven mechanism of action yet proven to work.

Agreed, but not knowing the full mechanisms at play is not the same as just making them up (chi).

2Scoops

samson09 wrote: »

The problem here is that anytime someone mentions alternative medicine, someone else just starts looking for evidence (scientific papers, usually double blind studies).

What exactly is the problem with this approach?

406C

samson09 wrote: »

Also, anytime that alternative medicine seems to provide any benefit, the majority here instantly jump on the placebo bandwagon. Do you hear what I'm saying?

whilst I wouldn't agree that it is the majority I do hear what you are saying.

I only wish I could harness the placebo effect more often and at will - wouldn't it be great

2Scoops wrote: »

Agreed, but not knowing the full mechanisms at play is not the same as just making them up (chi).

It is and thats my point 2scoops whats the difference in proposing a mechanism in terms that you understand from a mechanism proposed and understood in chinese medicine terms when it neither are proven and at least in one case when investigated has been disproven?

What about taking a different angle - can the Chi theory be disproven?

samson09 wrote: »

The problem here is that anytime someone mentions alternative medicine, someone else just starts looking for evidence (scientific papers, usually double blind studies).

2Scoops wrote: »

What exactly is the problem with this approach?

None but there is another side to care that evidence base doesn't cover, goal orientated care, and the fact that alot of the modern medicine we practice has no scientific or evidential (RCT Double blind) basis.

AtomicHorror

samson09 wrote: »

Also, anytime that alternative medicine seems to provide any benefit, the majority here instantly jump on the placebo bandwagon. Do you hear what I'm saying?

Well if a study, in this day and age, does not include a placebo group, then it is entirely appropriate to worry that the effect shown is due to placebo effect until shown otherwise. When we see cases like the acupuncture studies where the fake acupuncture and real acupuncture both caused equal pain reduction, then we can absolutely say that this is placebo effect. If you disagree when we make such claims, all you need to do SHOW US THE EVIDENCE. See, I put that in red caps because I'm so tired of typing it normally.

samson09 wrote: »

Basically, we all just need to chill out and respect other peoples opinions

What the hell are you talking about? If I say I reckon apple juice cures cancer should you "respect" that? Should I go unchallenged? Don't be ridiculous. Science shows no respect for opinion. That is a weakness and when the subject is health, that weakness means deaths and suffering.

Honestly, you come out with some crap but that just takes the biscuit.

AtomicHorror

406C wrote: »

None but there is another side to care that evidence base doesn't cover, goal orientated care, and the fact that alot of the modern medicine we practice has no scientific or evidential (RCT Double blind) basis.

Pointing at other stuff that is accepted without evidence doesn't make it correct for us to accept chiropractic without evidence. It means we're wrong to accept both.

AtomicHorror

406C wrote: »

Ah give over - no evidence for chiropractic - are you living on the moon?

Last I checked, the evidence was generally conflicting and of low quality even for pain relating to the back. For asthma and others it seems non-existant.

At any rate, that was not my point. You are making the suggestion that there are flaws in the evidence-based approach because 1. it does not consider goal orientated care and 2. there are other examples of accepted medicine with a poor evidence base. My point is that 2. is a logical fallacy. It is not correct to accept practice A despite lack of evidence just because practice B is accepted with similarly poor evidence. Also, point 2. is not a flaw in the evidence based approach, it is a lack of application of it.

Ihaveanopinion

@ Kipple

http://www.pubmed.com is a freely available online resource upon which you can access any abstract in scientific literature - at least those in Index Medicus. Many of the more important ones are freely available online or accessable in medical libraries - most of which are free to access.

It does not take a lot of money to access medical/scientific literature - just a bit of time and effort

406C

AtomicHorror wrote: »

Last I checked, the evidence was generally conflicting and of low quality even for pain relating to the back. For asthma and others it seems non-existant.

At any rate, that was not my point. You are making the suggestion that there are flaws in the evidence-based approach because 1. it does not consider goal orientated care and 2. there are other examples of accepted medicine with a poor evidence base. My point is that 2. is a logical fallacy. It is not correct to accept practice A despite lack of evidence just because practice B is accepted with similarly poor evidence. Also, point 2. is not a flaw in the evidence based approach, it is a lack of application of it.

so why is it accepted? And should we shun goal orientated care?

AtomicHorror wrote: »

Last I checked, the evidence was generally conflicting and of low quality even for pain relating to the back.

Low quality?

I just got this via email - its alot but referenced....

In 1985, a landmark study was published in the Canadian Family Physician 1 which researched the effects of chiropractic adjustments for people with severe and chronic lower back pain. The approximately 300 subjects in this study had been "totally disabled" by back pain for an average of seven years, and had exhausted all standard medical interventions.

The study found that after two to three weeks of daily chiropractic adjustments, between 79 and 93 percent of those patients without spinal stenosis (narrowed spinal cord) had good to excellent results, reporting substantially decreased pain and increased mobility. Even among those with a congenitally or developmentally narrowed spinal cord, a significant number showed substantial improvement. Remember that every single one of these people had gone through extensive, unsuccessful medical treatment prior to being allowed to participate as a research subject. After chiropractic treatment, over 70 percent of those studied were improved to the point of having no work restrictions. Moreover, follow-up a year later demonstrated that the changes were long-lasting.

In June 1990, BMJ published the Meade Study 2, a randomized clinical trial that determined that chiropractic treatment was more effective than hospital outpatient management for patients with low-back pain.

The conclusions of the first Meade study were straightforward: when compared to hospital outpatient care for low-back pain consisting of physical therapy, corset wearing, and exercises, chiropractic patients enjoyed more long-term benefits for up to two years.

The results of the follow-up study 3, published in the BMJ August 5, 1995, are even more compelling. With additional data now available, researchers learned that chiropractic patients not only reported less pain than hospital patients at six weeks, but three years later chiropractic patients reported a 29% greater improvement with chiropractic compared to hospital treatment.

In 1991 a two year multidisciplinary study conducted by RAND 4, the world renowned "think tank," in conjunction with the UCLA Department of Medicine, found that spinal manipulation was appropriate for the majority of acute low back pain. This two-year RAND study concluded that chiropractic management was safe, effective, and surprisingly well documented in numerous research articles.

Another study in 1991, compared chiropractic care to medical care back injury claims and concluded that for the total data set, cost for care was significantly more for medical claims and compensation costs were 10-fold less for chiropractic claims. It also found that chiropractic patients return to work ten times sooner after an injury. Total costs per case for the ICD-9 code for lumbar disc were found to be $8,175 for total medical care versus $1,065 for chiropractic care. 5

In 1993 the province of Ontario, Canada hired the esteemed health care economist Pran Manga, PhD to examine the benefits of chiropractic care for low back pain (LBP) and to make a set of recommendations on how to contain and reduce health care costs. His report "A Study to Examine the Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain" 6 cited research demonstrating that:

· Chiropractic manipulation is safer than medical management for LBP;
· Spinal manipulation is less safe or effective when performed by non-chiropractic professionals;
· There is an overwhelming body of evidence indicating that chiropractic management of low-back pain is more cost-effective than medical management;
· There would be highly significant cost savings if more management of LBP was transferred from medical physicians to chiropractors.

He also stated “A very good case can be made for making chiropractors the gatekeepers for management of low-back pain in the Workers' Compensation System in Ontario.”

In 1994, the American Agency for Health Care Policy and Research (AHCPR) publications confirmed the untested, questionable or harmful nature of many current medical therapies for LBP, and also stated that, of all forms of management they reviewed, only chiropractic care could both reduce pain and improve function 7.

A 2004 study in the journal Spine revealed that health care expenditure in the US for back pain sufferers was a staggering $90.7 billion in 1998, and that prescription drugs accounted for more than 15% of that figure 8. This is alarming since muscle relaxants have been associated with slower recovery rates, and steroid injections offer minimal relief. One needs to ask why drug costs continue to climb with this track record of slowing recovery and offering minimal relief?

A chronic pain study at the University of Washington School of Medicine 2005 9 recently compared which treatments were most effective at reducing pain for neuromuscular diseases and found that chiropractic scored the highest pain relief rating (7.33 out of 10), scoring higher than the relief provided by either nerve blocks (6.75) or opioid analgesics (6.37).

Another 4-year retrospective study in 2004 of 700,000 health plan members revealed that offering chiropractic services within a managed-care environment could save insurers 27% in back pain episode-related costs. 10

In December 2004, the British Medical Research Council published 2 papers in the British Medical Journal 11 [United Kingdom Back Pain Exercise and Manipulation (UK BEAM) Trial] demonstrating both the efficacy and cost-effectiveness of chiropractic compared with medical management. These two studies revealed:

· Spinal Manipulation, with or without exercise, improved symptoms more than medical care did at both 3 and 12 months.

· The authors concluded: “We believe that this is the first study for low back pain to show convincingly that both manipulation alone and manipulation followed by exercise provide cost effective additions to care in general practice.”

One of the more recent in a long line of articles showing the clear advantage of chiropractic management was published prior to this in May of 2007 12. Clinical and cost utilization based on 70,274 member-months over a 7-year period demonstrated decreases of 60.2% in-hospital admissions, 59.0% less hospital days, 62.0% less outpatient surgeries and procedures, and 85% less pharmaceutical costs when compared with conventional medicine.


REFERENCES
1. Kirkaldy-Willis W, Cassidy J: Spinal manipulation in the treatment of low back pain. Can Family Phys 1985; 31: 535-540

2. Low Back Pain of Mechanical Origin: Randomised Comparison of Chiropractic and Hospital Outpatient Treatment, Meade et al, British Medical Journal 1990 (Jun 2); 300 (6737): 1431–1437

3. Randomised Comparison of Chiropractic and Hospital Outpatient Management for Low Back Pain: Results from Extended Follow up, Meade et al, British Medical Journal 1995 (Aug 5); 311 (7001): 349–351

4. Shekelle PG et al, The Appropriateness of Spinal Manipulation for Low-Back Pain Indications and Ratings by a Multidisciplinary Expert Panel, RAND Corporation, Santa Monica, CA, 1991

5. Jarvis, K.B., Phillips, R.B., Morris, E.K. (1991) "Cost per Case Comparison of Back Injury Claims of Chiropractic versus Medical Management for Conditions with Identical Diagnostic Codes". Journal of Occupational Medicine, Vol. 33 (8), pp. 847-852.

6. Manga P, Angus D, Papadopoulos C, Swan W. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain; Richmond Hill, Ontario: Kenilworth Publishing, 1993

7. Clinical Practice Guideline 14 AHCPR Publication No. 95-0642: December 1994

8. Estimates and Patterns of Direct Health Care Expenditures Among Individuals With Back Pain in the United States Luo X, Pietrobon R, Sun SX, Liu GG, Hey I Spine 2004 (Jan 1); 29 (1): 79–86

9. Chronic Pain in Persons With Neuromuscular Disease Jensen MP, Abresch RT, Carter GT, McDonald CM Arch Phys Med Rehabil 2005 (Jun); 86 (6): 1155–1163

10. Comparative Analysis of Individuals With and Without Chiropractic Coverage: Patient Characteristics, Utilization, and Costs Antonio P. Legorreta; R. Douglas Metz; Craig F. Nelson; Saurabh Ray; Helen Oster Chernicoff; Nicholas A. DiNubile Arch Intern Med 2004 (Oct 11); 164 (18): 1985–1892

11.United Kingdom Back Pain Exercise and Manipulation (UKBEAM) Trial British Medical Journal 2004 (Dec 11); 329 (7479)

12. Clinical Utilization and Cost Outcomes from an Integrative Medicine Independent Physician Association: An Additional 3-year Update Sarnat RL, Winterstein J, Cambron JA. J Manipulative Physiol Ther. 2007 May;30(4):263-9.

RobFowl

"In June 1990, BMJ published the Meade Study 2, a randomized clinical trial that determined that chiropractic treatment was more effective than hospital outpatient management for patients with low-back pain."

Small point but IMO this says more about the poor quality of care for LBP in hospital OPD's .

Dr Galen

just a small point but just because something is published doesn't necessarily mean it is of quality, that is where decent critical analysis comes in and always will, no matter what your talking about.

406C

Mystik Monkey wrote: »

just a small point but just because something is published doesn't necessarily mean it is of quality, that is where decent critical analysis comes in and always will, no matter what your talking about.

and when 'peer reviewed' journal publication comes into play... take a look at the references

RobFowl wrote: »

"In June 1990, BMJ published the Meade Study 2, a randomized clinical trial that determined that chiropractic treatment was more effective than hospital outpatient management for patients with low-back pain."

Small point but IMO this says more about the poor quality of care for LBP in hospital OPD's .

exactly and that chiropractic care excelled and in the second Meade study it was long term so why advise a patient to enter into the hospital system of management rather than refer to a qualifed reputable chiropractor in your area?

tallaght01

406c, you've been warned about just copying and pasting. Like we said before, it's no use to just post something you got in an email because it's referenced.

You need to discuss the references, and critically appraise them.

If it happens again, your ban will be made permanent. No one can enter into a logical discussion with you, if you regard emails as evidence!!!!!!!

Dr Galen

406C wrote: »

and when 'peer reviewed' journal publication comes into play... take a look at the references

sorry i don't get you here 406c? what do you mean?

Dr Galen

406C wrote: »

What?? :rolleyes: So I can't post an article just because I got it via email? Come on

What is the problem? Are you afraid to discuss what I have posted because it now has references to back up what I have said? :eek:

i'm more than happy to discuss the articles that you have posted references to, but in order to do that properly, I'd need to read each one and make up my mind about the validity of each.

You appear to have read them, so would you care to summarise, or at least start the discussion ball rolling? Good points? Bad points? Sample sizes? Methodologies? Results? Conclusions? Limitations and ideas for further study?

tallaght01

406C wrote: »

What?? :rolleyes: So I can't post an article just because I got it via email? Come on

What is the problem? Are you afraid to discuss what I have posted because it now has references to back up what I have said? :eek:

I have to go to work now. But I'm going to review your posts when I get home. You've just continued to take the piss, when all I asked was for you to discuss your references. I know you won't give a flying flute about being banned, but that's definitely the way you're heading.

Dr Galen

i'm still here and willing discuss things 406C, do you want to answer my post above Tallaght01's?

406C

Mystik Monkey wrote: »

i'm still here and willing discuss things 406C, do you want to answer my post above Tallaght01's?

Not avoiding your post Mystic I took out a number of parts out myself that I had read through and held no favour for, for example one article from Spine in 2008 that quoted that if you went to a chiropractor you were less likely to be chronically disabled - however it gave no idea of how serious the injury presenting was nor its long term prognosis. On the other hand it may have been that those attending a chiropractor were better off and able to return to work faster - but it could have easily been argued either way.

The meade studies are solid as is the canadian Manga study - I am short for time so I won't link them but they are easily found on the net and the executive study of the Manga report makes good reading.

Reference 12 looks particularly good - especially when you take into account the rigmarole of consultant visits, MRIs. CAT scans, xrays and resultant non diagnosis into account.

We need to seriously look at the wasteful spread of costs within the health care system, savings and those services that are life saving for the Irish pubic and start taking decisions that before we were unwilling to take.

This includes chiropractors and perhaps referring patients to them before referring them into the hospital system as some sort of screening mechanism to weed out those actually beyond conservative care instead of continuing to waste reducing resources allocated to public health care.




.

AtomicHorror

406C wrote: »

so why is it accepted?

Perhaps it should not be, but that is another discussion.

406C wrote: »

And should we shun goal orientated care?

Again, this is not my point.

406C wrote: »

Low quality?

I just got this via email - its alot but referenced....

<snip>

What are you not getting? You addressed the very part of my post that I stated as being beside the point. And you addressed it with a vast chunk of text.

You've ignored the point I was making entirely.

tallaght01

406C wrote: »

You're probably right there Tallaght01 since I have not seen anything on this forum come to much and I am probably longer in the tooth than most of you on here and realise there is much more to health care than <edited for trolling>.

Your own back is bunched and rather than try a good chiropractor (and the Aussies are some of the best trained I have ever met) you would rather suffer and reduce your quality of life.

Whilst I have no bother dismissing BS therapies including Angel cards crystals etc etc - I have no problem considering and trying therapies and professions which were getting it right when our profession was still bleeding people and using leeches because I put my patients first.

Now Tallaght01 you have admitted the medical approach to LBP is rubbish - how bad will it have to get before you try a chiropractor or will you allow it reach a point of regret.

Goodnight and hope you're shift goes better than it would within the HSE Hospital system here

Sincerely best wishes

Only lastw eek I spoke to a chiropracter I know, and asked him to slot me in for a session in a week or two.

But the real issue here is how you've now talked about how you thought some of the evidence above was unreliable and you left it out.

So, share the good stuff with us. The onus is not on us to take your word. Make people want to read what you've linked. tell us you've linked to a trial. Then tell us about the sample size, the outcome measurement, the intervention, the placebo group, the study design, whether the results were statistically significant.

if you do that, then I guarantee people will engage you,a nd we'll make sure they do it civilly. if you just continue to troll, then we can just part company.

But presenting some data would be very welcome, and would be a valuable addition to the forum.

406C

AtomicHorror wrote: »

You've ignored the point I was making entirely.

I probably did since it was no real point - ie your argument was that modern medicine may have no evidence to back up some of what it does and that fact that the evidence to show other therapies do it better is low quality so it doesn't count isn't really an argument of any weight or bearing against those therapies having evidence of doing it better.

tallaght01 wrote: »

Only lastw eek I spoke to a chiropracter I know, and asked him to slot me in for a session in a week or two.

Good for you - what if he suggests an xray? Electromyography? What if he suggests a course of care over an extended period because the discs appear to have non age related degeneration?

As I understood it you hadn't engaged any chiropractors for which you held respect?

tallaght01 wrote: »

But the real issue here is how you've now talked about how you thought some of the evidence above was unreliable and you left it out.

yes

tallaght01 wrote: »

So, share the good stuff with us. The onus is not on us to take your word. Make people want to read what you've linked. tell us you've linked to a trial. Then tell us about the sample size, the outcome measurement, the intervention, the placebo group, the study design, whether the results were statistically significant.

I have on two threads now shared the good stuff and the 'article' I posted above in many cases goes through these very point and where it didn't I relied on my memory of reading them, their reputation, for example the RAND, AHCPR, British Medical Research Council, Insurers or The Manga Report, or Journals that would hold no bias for chiropractic like The Journal of Occup Medicine.

tallaght01 wrote: »

But presenting some data would be very welcome, and would be a valuable addition to the forum.

The data is in the article Tallaght01 and presented in an easy to read manner.

tallaght01 wrote: »

if you do that, then I guarantee people will engage you,a nd we'll make sure they do it civilly. if you just continue to troll, then we can just part company.

Thats fine as you pointed out you thought I didn't 'give a flute' then edited my reply.

tallaght01

406c, can I just point out that, despite repeated requests to DISCUSS the evidence, rather than posting links, or links to interpretations of it, you're just going to rely on the kind of thing you posted in post number 31 above as evidence.

Just confirm that with a yes or no before we review your situation here, if you could please.

Thanks.

tallaght01

Cheers,

I'll get back to you about your banning if mt other mod colleague agrees with it.

If it happens, it can be rescinded at any time if you were to message me with a post that deals with the evidence in a non trollish way. If that happens I'll post it in the forum, and unban you.

BUt we just can't keep up with your trolling. I have literally NEVER had posters contacting me asking me to ban people before you and sampson09 started posting here.

I believe you're taking away from people's enjoyment of the forum.

I've never banned anyone before. But I can't just keep asking you over and over to comply with the basic rules. It's all a shame, because I'd love a proper evidence-based debate about CAM.

But bear in mind what I said about getting your ban rescinded. It would be very easy.

kipple

<Deleted for just linking evidence, with no discussion of the study. I've asked this several times. It's just bang my head off a brick wall stuff. Next one is a ban>

AtomicHorror wrote: »

When we see cases like the acupuncture studies where the fake acupuncture and real acupuncture both caused equal pain reduction, then we can absolutely say that this is placebo effect. If you disagree when we make such claims, all you need to do SHOW US THE EVIDENCE. See, I put that in red caps because I'm so tired of typing it normally.

No or not without more evidence.

A number of posters have stated that effects of acupuncture is because of the placebo effect. This to me is a clear signal that many people on the form are not willing to accept any CAM in any shape or form. Worse it shows a lack of scientific curiosity on a forum that is for discussing biology.

The fact that the meridian system is bogus does NOT mean that the effects from acupuncture are from the placebo effect. Really provide the evidence that shows the causal relationship.

I offer the following paper which MAY provide a explanation based on a neuropepitde release explanation of acupuncture.
Link Removed by kipple by request of tallaght01


Fascia is the soft tissue system that permeates the human body forming a whole-body continuous three-dimensional matrix of structural support. Doctors here will remember fascia as that stuff you get rid when doing dissections so you can get to the good stuff. For non doctors it is the white substance between the skin and meet of a chicken. Long ignored this connective tissue is turning from the ugly stepsister into the Cinderella of medical research. There is a growing body of research looking at the importance of fascia in the fields of neurology, health and pathology.

Lets look at the traditional model of movement. Simply put muscle pulls on tendon pulls on bone and we move. In real bodies muscles are not functional units. The functional unit is a motor unit. Muscular movements are generated by many motor units which are distributed over many muscles. These forces are transmitted to a complex network of fascial sheets which then transfer into the final body movement. Muscles dont transmit their full force to the skeleton via tendons they distribute this force into the fascial network.



While searching for the above paper I was excited to found a paper looking into the relationship between lower back pain and posture. It hypothesized - "that individuals who habitually adopt passive postures for long periods, may de-activate and potentially de-condition the stabilizing muscles of the lumbo-pelvic region."

Why is this exciting? As a Rolfer I work with peoples posture for example looking at how people sit, educating them on better sitting patterns and releasing the restrictions that stops them from sitting naturally. If a client can achieve a better everyday posture then the likelihood of having back pain is decreased. It is easy to assume for all of us here that better posture leads to less back pain and it is nice to find a bit of research that supports this.
Link Removed by kipple by request of tallaght01

tallaght01

Discussed with DrIndy. 406c banned for a month.

Prime Mover

There was something very familiar about all that aggro. There was a poster called N8 a while ago that was very argumentative as well.

Seems they both share the same taste in 406 coupes as well.
http://www.boards.ie/vbulletin/showthread.php?p=55058526#post55058526

They must be on special offers to chiropractors.

tallaght01

Hi guys.

Look, I've deleted a load of posts in this thread that were basically just aggro, in some kind of attempt to get things back to normality.

I've deleted some posts from our more pleasant posters, because they just dealt with the points that were being deleted. Apologies to those who had their posts deleted.

let's just try and answer the original question on this thread.

Any more discussion on CAM as a topic can be continued on the relevant thread on here (the thread looking for opinions on CAM topics).

Mucco

kipple wrote: »

The National Institute for Clinical Excellence is a great sounding title but does any body here have opinions on how reliable this group is.

NICE are the UK body that guides how to spend the NHS's £100 billion budget, so they have probably a fair idea what they're talking about.

The report on back-pain is here:
http://www.nice.org.uk/nicemedia/pdf/CG88NICEGuideline.pdf

It is fair to say that chronic pain is an area that is lacking wrt pharmacological treatments, though many pharma companies are researching this area at the moment.

ergo

Mucco wrote: »

NICE are the UK body that guides how to spend the NHS's £100 billion budget, so they have probably a fair idea what they're talking about.

The report on back-pain is here:
http://www.nice.org.uk/nicemedia/pdf/CG88NICEGuideline.pdf

It is fair to say that chronic pain is an area that is lacking wrt pharmacological treatments, though many pharma companies are researching this area at the moment.

I think NICE produce some excellent guuidlines but there is a perception among some (not all) in the UK that, at times, they're as much about cutting costs as about the scientific evidence...those people refer to them as the "National Institute for Cutting Expenditure".......at the same time I re-iterate, imho some of their guidelines are excellent

AtomicHorror

kipple wrote: »

A number of posters have stated that effects of acupuncture is because of the placebo effect. This to me is a clear signal that many people on the form are not willing to accept any CAM in any shape or form. Worse it shows a lack of scientific curiosity on a forum that is for discussing biology.

Well actually I'm quite open to the possibility that there is more than placebo effect involved in the beneficial effects of sham acupuncture. But right now it's not all that clear what's going on there so I think that we could argue that placebo is playing a major role. I absolutely think that acupuncture warrants more research because even if it is mere placebo effect, it seems remarkably potent and reliable. But as you say the traditional philosophy that surrounds acupuncture is clearly not relevant beyond possible placebo value for those who could be "unblinded" by sham acupuncture.

tallaght01

kipple wrote: »

While searching for the above paper I was excited to found a paper looking into the relationship between lower back pain and posture. It hypothesized - "that individuals who habitually adopt passive postures for long periods, may de-activate and potentially de-condition the stabilizing muscles of the lumbo-pelvic region."

OK, so tell us about the paper. Is it a good paper.

Just to clarify..I never asked kipple to remove links. I said not to post them if you can't discuss the papers.

I deleted your post because you're making claims without being able to discuss the evidence. You're doing it again. So, tell us about the study, or take a week off.

Thanks.

sam34

ergo wrote: »

I think NICE produce some excellent guuidlines but there is a perception among some (not all) in the UK that, at times, they're as much about cutting costs as about the scientific evidence...those people refer to them as the "National Institute for Cutting Expenditure".......at the same time I re-iterate, imho some of their guidelines are excellent

somewhat OT, but there was no psychiatrist on the panel that drew up the NICE guidelines for ECT... go figure :rolleyes:

drzhivago

sam34 wrote: »

somewhat OT, but there was no psychiatrist on the panel that drew up the NICE guidelines for ECT... go figure :rolleyes:

am worried about NICE references in general coming anywhere near Ireland

At present if a treatment is proven and medical professional wants to prescribe and the medication is licenced they can

Not in UK because of NICE which has led to geographic differences in access to a supposed National health Service

SomeDose

drzhivago wrote: »

am worried about NICE references in general coming anywhere near Ireland

At present if a treatment is proven and medical professional wants to prescribe and the medication is licenced they can

Not in UK because of NICE which has led to geographic differences in access to a supposed National health Service

But a guideline is just that - a guideline. It's not supposed to replace clinical judgement, and it doesn't absolutely restrict prescribing. The thing is, in many cases, saying something works and is licensed is no longer sufficient justification for choosing it. Health boards have a finite amount of money (i.e. never enough) so cost-effectiveness is a priority in choosing treatments. For example, atorvastatin is proven and licensed for treatment of hyperlipidaemia, yet there is seldom any justification for it to be used as first-line treatment because there are other drugs that will achieve the same outcomes for a fraction of the cost (despite what the Pfizer reps may tell you). So why waste money on it?

We all hear about the high-profile cases of people getting refused high-tech drug treatments for cancer etc because of the costs involved. The Daily Mail loves these kind of stories. I won't argue the rights and wrongs of these decisions, but £20k spent on some drug that may or may not produce a favourable outcome is £20k that some other part of healthcare must now do without. NICE are by no means perfect, but sometimes the media doesn't really give the true picture behind their decisions.

cltt97

I'm afraid I don't have much "scientific evidence" to offer, other than my own experiences, which are good enough to me. Like any poor back pain sufferer, one day I woke up with backpain and I did all the things one would normally do. I went to the GP, she did blood tests to make sure I didn't have rheumatoid arthritis and sent me to an X-ray. The x-ray was confusing and I was sent to a specialist. The specialist could not see much so sent me for a bone scan and an MRI (all of which I had to pay for unless I wanted to wait for a year). Whilst all this was going on I was put on antiinflammatories, but life was agony and I got depressed and was in awful pain most of the time. The MRI came back with nonspecific observations, the bone scan was fine. I went to physiotherapy for ages with no relief and the physiotherapist gave up on me. I tried another one, same result. I tried accupuncture, that didn't work for me. I went to one chiropractor, it helped a little but not massively. I saw another two specialists, spinal surgeons, one of which said he could fuse some vertebras but that probably wasn't worth the effort and referred me to a pain clinic for epidurals and injections... I felt this wasn't the way for me, too risky (read up on epidurals and associted risks) and only treating the symptoms. One GP put me on Aulin then saying this would avoid getting stomach ulcers, well I got vertigo instead and when asking him he said antiinflammatories would only upset your stomach and gave me anti-vertigo tablets. I didn't take them and an osteopath advised that vertigo was one of the top contraindications of aulin. Thank god I went off them, seeing that they actually killed people.
I then started looking at "more" alternative therapy because I was getting desperate. I ended up with a bi-aura practitioner, and things started shifting. Three treatments in and I ended up in a weird position and some sharp pain went down my leg and something seemed to go back into place. From then on things got better. I'm not saying I was miraculously healed but the improvement was very noticable. I've since then been going to a chiropractor and have also tried amatsu, I've also done a course of rolfing
, all of which helped to maintain a reasonable painfree managable life. Strengthening excercises and attention to posture is also vital. I don't think that "back pain" as such can be put into one pot and that there is something that can be proven to work (all the time), as everyone is different. I'm a scientist myself (not a medic I must admit) and I spend countless hours reading scientific publications and scrutinise evidence in my line of work, but from my own experience all I can say that sometimes western medical science just can't provide the answers or relief but one can sometimes find relief in alternative treatments. They might not be scientificaly proven to work, and there is a lot of jokers out there - and I've come across a few - but in the end, the patient has to take charge of their pain and do what's right for them, and as such should not be brandished for doing so, or ridiculed for trying and then put into the "but it was the placebo effect" category. I have a high regard for the medical science, my current GP is wonderful, but as the old saying goes, I believe that "absence of evidence is not evidence of absence"
My two cents to this thread...

AtomicHorror

cltt97 wrote: »

I'm afraid I don't have much "scientific evidence" to offer, other than my own experiences, which are good enough to me.

But how do you know whether you've experienced genuine healing, placebo effect or just regression to the mean? Many conditions get better over time without intervention, and that's bound to happen at the same time as something by coincidence. Can you see how, even with this happening only rarely, anecdotal evidence would create a false sense of efficacy?

cltt97 wrote: »

I have a high regard for the medical science, my current GP is wonderful, but as the old saying goes, I believe that "absence of evidence is not evidence of absence"

But what does that really mean at the end of the day? I can say the same of unicorns, God and leprechauns. Is it satisfactory for me to point to any of these and say "absence of evidence is not evidence of absence?". The answers will seem to differ depending on what a person already believes in. Does making such an argument from ignorance logically support any positive position?

What about new drugs? Is absence of evidence of efficacy okay? Is absence of evidence of safety okay? If not, why is it okay for alternative medicines? If they really have the same capacity to heal you as conventional medicine (or better) then don't they conceivably have the same capacity for harm?