Accepted Therapies – What Research?

In a review of research on the topic of evidence it was reported that about 75-85% of all medical treatments are evidence based.  In this review, evidence based included non-experimental evidence most often reported to mean unanimity among physicians that there was convincing non-experimental evidence.  Only about 30-40% of all treatments in these studies were based on Randomized Controlled Trials (RCTs).  Here is another similar review with citations.

There are levels of quality in evidence. RCTs are currently held as the gold standard of evidence, but some treatments don’t lend themselves to testing in this manner or are common sense.  Even in RCTs there are always outliers that don’t conform.  If we could do an RCT for every treatment that would be great, but we can’t.  Evidence based treatment relies on doctors to make the best decisions based on all the evidence available to them at the time.  So I’d say that 85% of medical treatments are based on evidence and a judgment call. That, is good.

There does seem to be a double standard in this area of discussion.  When it comes to traditional medicine the levels of accepted evidence are understood.  When it comes to complimentary and alternative treatments (CAM) anything less than an RCT is refused as evidence.  Because of this bias chiropractic has been forced to prove it’s self by performing RCTs.  And research has now found about 68% of all chiropractic procedures are backed by RCTs.  Compared to 30-40% of medical treatments.  That is also good.

I appreciate having good research to support my profession.  I’d really like to stop hearing that chiropractic is not founded in evidence, but that may not happen.  On a slight tangent, and to give you a thought provoking sampling, here are a few common treatments that either have limited evidence or research that actually finds that they don’t help.

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7 thoughts on “Accepted Therapies – What Research?

  1. redrabbitslife

    Huh? How does pointing your finger at other people and saying: “you don’t have evidence for that either” prove that chiropractic is helpful.

    I’ve delivered over 300 babies and I’ve never cut an episiotomy. The episiotomy is old school and on its way out due to lack of evidence.

    Therapeutic ultrasound is a scam, and any real MD would tell you so.

    Back fusion surgery, I can’t comment on. I thought it was more to prevent worsening neuro status, but I’m no neurosurgeon.

    Drug recalls are a good thing. I don’t know about FenPhen, but I do know about Phase IV or post-marketing trials wherein longer term effects and vanishingly rare events are measured that may not have been seen. Perhaps more vigilance is needed in Phase III.

    That still does not prove chiropractic has any benefit. Studies please! Randomised, placebo controlled would be best, but cohort would be acceptable to start. Then you’ll get me and all the other skeptics on board.

    I hope you can treat blood pressure. It would be great to get these folks off meds.

    Reply
    1. cmnacnud Post author

      Exactly my point, and thank you. This post was not about proving that chiropractic has benefit but to point out that our society has a double standard, accepting lesser proof from medicine than from alternative health treatments. You have just demanded of me, greater proof than is demanded in medicine.

      “Studies please! Randomised, placebo controlled would be best, but cohort would be acceptable to start.”

      You gave anecdotal evidence about episiotomies and blasted Ultrasound without justification. I provided studies and links. In the studies I cited only 30-40% of medical procedures have studies of any kind to back them up. I also listed for you a study that showed that 68% of chiropractic treatments have studies to back them up. Though, I would like to stop hearing that it’s not evidence based when it is more evidence based than medicine, based on these studies. I am not trying to say medicine is bad for the low number nor that chiropractic is good because of theirs, merely pointing out the double standard.

      If you do want to read the studies, you may, they are there. I like that chiropractic has been shown through studies to be evidence based. I am a fan of evidence based care, however, evidence does not always mean a study. For example: it would be unethical to do a study to see if a tracheotomy is better than a placebo. I too hope that episiotomies are on the way out and that chiropractic can treat high blood pressure. I hope that all physicians make evidence based decisions. I also hope the double standard would be cleared up and that equally high standards would be applied across the board.

      Reply
  2. redrabbitslife

    OK, did you read that study? It was a survey of 180 patient encounters. It does not mean that 68% of chiropractic is evidence-based. What a ridiculous claim!

    If that’s what you do with numbers, I don’t trust you to count the change from coffee, never mind messing with my back.

    Reply
    1. cmnacnud Post author

      That survey of 180 patient encounters was as good as the surveys of patient encounters done by the medical research that I mentioned. Better than many of them. I was comparing apples to apples. The studies were similar and followed similar procedures and came to similar conclusions. They are by no means absolute proof, I agree. I also agree that further studies would be great to see. Based on the studies as a whole my claim was justified. It seems that you are still trying to hold chiropractic to a higher standard than medicine. You have ignored the overall point and used logical fallacies to debate.

      I don’t mind a discussion and you are welcome to point out mistakes, but personal attacks will not be tolerated. I have not attempted to demean you in any way. Please do not attempt to insult me or any other posters here again or you will no longer be permitted to post on this blog.

      Reply
  3. redrabbitslife

    I was frustrated with what I see as a thorough misrepresentation of a small and relatively uninteresting study, and I apologise for my harshness.

    This sort of study is not particularly informative as it does not address what any evidence in question says about the given therapy. Sure, it’s an RCT, but I have seen lots of RCTs get mangled, both by pharma and by CAM practitioners. Does the RCT support the therapy? How many people were involved in the study in question? What were the biases? Is there another explanation for the result? Is the study population comparable to my patient population?

    For medicine to make meta-analyses of any quality, these have to be addressed.

    The reason we ask for high quality evidence is because there is no good mechanism for chiropractic to treat, for example, asthma. If it does, great, fabulous. Let’s discover how! But quoting a small study like this to mean “research has now found about 68% of ALL chiropractic procedures are backed by RCTs” is an exaggeration at best. All? Hm.

    Reply
  4. cmnacnud Post author

    I agree that the studies in question are lacking and bring up further questions. I have yet to find a perfectly performed or reported study. You are right, these also have their flaws. I believe these studies were done as a baseline to give us an idea of where we currently stand and where we need to focus our efforts for improvement, so to claim these as proof of everything would be wrong. I will admit that declaring that this research applies to the entirety of chiropractic is overzealous. These studies are merely a snapshot of a whole. Extrapolating out from studies to reality is always flawed, just like assuming every patient is the same as the textbook.

    To bring some anecdotal evidence to this discussion I’d like to give a possible reason for higher numbers than would normally present to our mind. In any given day a doctor either medical or chiropractic will provide many routine treatments that they do every single day. I’ve worked in medical offices that only do about 20 kinds of procedures on a regular basis. Sure we do more, but not routinely. In my chiropractic office I typically see the same thing. I was shocked after having texts of pathology and treatments drilled into my head to get out of school and find that most patients present with the same or similar condition. I love when a tough case presents. I imagine (hypothesis here) that it is similar in most offices. It is nothing like the TV shows where we are shown the worst problems an ER doctor will see in a year all in 30 min. On any given day I may analyze my treatments and find that I have only done a few kinds of treatments over and over, and all of them are well proven treatments. Because of my hypothesis, I am surprised by how low numbers were in both medical and chiropractic studies. I would love to find out which treatments they found to be unsupported by evidence and determine why we are still doing them.

    If we were to list the number of procedures that a doctor can perform and then rank them by how often they are performed the procedures performed the least often, I would guess, would also have the least amount of research behind them, with exceptions. I’m pretty sure the insurance companies already have a list like this. If anyone can get a hold of it I’d love to see it.

    The idea is not lost on me that extreme claims require extreme evidence. I feel that this must be applied across the board. The bulk of chiropractic treatment is not a huge leap. Treatment of low back pain (LBP) has obvious links to chiropractic manipulation as do cervicogenic headaches. These types of things are the bulk of chiropractic yet even with RCTs they are still accepted less than say fusion for LBP which has very low efficacy.

    If chiropractic can improve cases of asthma then because there is not an obvious link I would expect an RCT to be done before claiming that chiropractic treats it. I also will not wait for an RCT to be performed if I find a treatment that helps my patient. If, while treating a patient’s facet sprain we find improvement in their asthma with no other explanation, I will happily continue rendering that treatment until maximal medical improvement is seen. If they respond to care then I am basing my treatment on evidence. I have not had occasion to treat a patient for asthma with chiropractic manipulation. I have however posted information on my single weak case study with bed wetting as well as vocal performance here on the blog.

    Reply
  5. redrabbitslife

    Great. And the higher quality evidence you have, the more support you’ll get from the mainstream.

    What can I say? I am happy with chiropractic treatment of back pain and headache, but I can’t refer to chiropractors because I have yet to meet a chiropractor locally whose practices I trust on other counts. I don’t want to confuse my patients.

    My style of banter, as in the post that offended you, incidentally, is the style I use for pharma reps who show up in my office with over-interpreted research, so please don’t feel too singled out. I pick them apart much more carefully than anything I do on the internet

    Reply

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