S

eizing on the opioid epidemic as a chance to expand their reach, naturopaths and chiropractors are aggressively lobbying Congress and state governments to elevate the role of alternative therapies in treating chronic pain. They’ve scored several victories in recent months, and hope the Trump administration will give them a further boost.

Their most powerful argument: We don’t prescribe addictive pain pills.

Shunning pharmaceuticals, they treat pain with everything from acupuncture to massage to castor oil ointments. They offer herbal supplements and homeopathic pills.

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There’s little rigorous scientific research to back up such treatments. Yet patients often say they feel relief. And providers say their alternative approaches are vitally needed at a time when more than 30,000 people a year die of opioid overdose in the US alone — and half of those deaths involve a prescription painkiller, according to the Centers for Disease Control and Prevention.

“I am surprised that with the crisis where it is today, more people aren’t picking up on alternative treatments,” said John Falardeau, a senior vice president with the American Chiropractic Association.

Chiropractors scored a big victory recently in Oregon, where the state Medicaid program decided to cover spinal adjustment for lower back pain starting in 2016. Vermont, Virginia, and Nevada are considering similar moves.

Another win came earlier this year, when the American College of Physicians recommended non-surgical interventions such as acupuncture, yoga, and chiropractic care as the go-to treatments for lower back pain.

“The American College of Physicians is our new best friend,” said Robert Hayden, a Georgia chiropractor and spokesperson for the American Chiropractic Association. Hayden said the the industry considers the decision “a direct result of the fact that we are in an opioid crisis in this country.”

Hoping for help from the Trump administration

Hoping to make even more inroads, both naturopaths and chiropractors are lobbying Congress to push the Veterans Affairs health system to hire alternative providers. Chiropractors are also pushing for a role in the National Health Service Corps, which puts providers to work in community health centers, often in rural areas.

And this month, naturopaths will descend on Washington, D.C., for a meeting all about chronic pain. “Naturopathic doctors are poised to be the leaders in combating the opioid epidemic,” the promotional materials claim.

The pain workshops will be followed by a three-day conference to set a lobbying agenda and teach naturopaths organizing techniques.

The American Association of Naturopathic Physicians clearly sees an opening to make gains: The arrival of the Trump administration and a new, Republican-controlled Congress “opens up new opportunities for AANP to push for insurance non-discrimination, to have [naturopaths] included in the VA, and to emphasize that naturopathic care is a much-needed alternative to opioids for the treatment of chronic pain,” the AANP website declares.

Chiropractors, too, are hopeful. President Trump has talked about giving more Americans access to flexible spending accounts for health care. That, they say, will make it easier for consumers to pay for treatments that insurance doesn’t cover — like chiropractic care.

“I think they see an opening. Whether it actually works or not is secondary. It’s basically an opening for them to try to claim some legitimacy.”

Dr. David Gorksi, surgical oncologist

Some mainstream doctors — who often range from skeptical to fiercely critical of alternative medicine — are wary. They worry that naturopaths or chiropractors might persuade patients with serious diseases to shun conventional medical care. And they point out that some herbal treatments interact badly with chemotherapy or other pharmaceuticals.

Other skeptics dismiss the push to claim a role in treating pain as a public relations ploy.

“I think they see an opening,” said Dr. David Gorski, a surgical oncologist and an editor of the blog Science-Based Medicine. “Whether it actually works or not is secondary. It’s basically an opening for them to try to claim some legitimacy.”

He finds it particularly galling that alternative providers often mix sound advice on diet and exercise, drawn from mainstream medicine, with fringe therapies that have no evidence behind them, like homeopathy pills. “It becomes hard for the average person to figure out what is and it isn’t quackery,” he said.

But other doctors are cautiously embracing the idea of new ways to treat chronic pain. They say if alternative remedies help — even if only through a placebo effect — patients may be able to avoid addictive pills.

Helping patients gain control over their pain

Emily Telfair, a naturopath in Maryland, said she often sees chronic pain patients who feel frustrated that conventional treatments haven’t worked to treat their pain. Or those patients haven’t been able to tolerate the tough side effects of pain medication. They come to her hoping for relief.

“That’s the place where naturopathic medicine shines. It offers another option for folks who haven’t found help,” Telfair said.

Telfair uses massage therapy, including a specific type of treatment known as craniosacral massage. She also sends patients home with castor oil packs and topical creams to apply to their pain points, all of which she said are noninvasive ways “to invite the body to heal and let go of the chronic symptom.”

“It offers another option for folks who haven’t found help.”

Emily Teflair, naturopath

She said her job isn’t always to cure a patient’s pain — it’s to help patients see that their pain won’t always be unrelenting and oppressive, and to help them gain control.

“Knowing their pain can be different from one day to the next, that is a very powerful tool,” she said. “I know I can’t help everybody with chronic pain. But you [can] change the person’s relationship to their pain.”

That’s been the case for 70-year-old James Fite, who has had both hips replaced and now needs a shoulder replaced. He’s hesitant to have the surgery because of his chronic pain.

“It’s always there. Sometimes it’s just blinding, excruciating,” he said. But he’s found relief with an acupuncturist and naturopathic care from Telfair.

He uses roll-on castor oil, sticks to an anti-inflammatory diet, and also receives massage therapy. Other times, he takes opioids. Fite said he has had 15 providers trying to treat aspects of his pain. He feels his acupuncturist and Telfair are the most “tuned in” to his body’s condition.

“None of these things are cure-alls for a chronic condition like mine,” he said. “But I’ve gotten as much help from them as from anybody.”

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With various combinations of treatments, Fite said he’s more able to manage his pain than he has been before. He’s found the energy to teach chess after school twice a week at a nearby library and can spend more time playing with his grandkids.

Other naturopaths said they see their goal as finding and addressing the root cause of a patient’s pain. And they argue they have more time than a medical doctor to do that.

“It’s not as simple as a replacement for an opioid. We treat the cause of the pain. We don’t just mask it with a painkiller,” said Michelle Brannick, a naturopathic provider in Illinois who markets her services specifically to pain patients. Brannick relies on homeopathic arnica and herbal supplements, among other treatments.

A cautious approach from physicians

Taxpayers subsidize roughly $120 million a year in federal grants to research alternative medicine through the National Institutes of Health.

Even after all that research, Dr. Josephine Briggs, the director of the NIH’s National Center for Complementary and Integrative Health, said she is aware there isn’t much robust evidence to support many alternative pain therapies.

“We can’t call this a slam dunk. This is not a situation where we’ve got an easy answer for a tough clinical problem,” she said.

But she pointed out that many alternative remedies are fairly low-risk. And some physicians are opening their minds up to the idea — with caveats.

“As a physician, I would never just say, ‘You have pain, so we’re going to just put you on pain medicine,’” said Dr. Andrew Esch, a clinician and consultant with the Center to Advance Palliative Care in New York.

Doctors stress that pain can vary wildly from one patient to the next, and treatments won’t be the same for every patient, either. “Sometimes that’s physical therapy and Motrin, sometimes it’s acupuncture and antidepressants,” said Esch.

Dr. Charles von Gunten, a palliative care specialist at OhioHealth, agreed alternative therapies like acupuncture and massage can be part of a doctor’s toolkit.

“They’re not either-or types of approaches,” he explained.

“As a physician, I would never just say, ‘You have pain, so we’re going to just put you on pain medicine.’”

Dr. Andrew Esch, palliative care expert

But doctors also are leery of sending cancer patients or others with serious illnesses to a naturopathic provider who might convince them to go off of chemotherapy or forgo conventional medical care.

“That’s certainly a concern,” said Briggs. There’s also concern that homeopathic remedies like St. John’s wort will interfere with a patient’s prescribed medication and make those drugs less effective. Encouraging pain patients to experiment with alternative treatments might open the door to those risks.

But Esch said he doesn’t see those concerns as a reason for doctors to dismiss naturopathic approaches that their chronic pain patients are interested in trying. Most patients he sees are using some sort of alternative treatment — and many will continue to do so whether doctors like it or not, he said.

“If someone is going to take shark cartilage because they think it will make their pain better, my approach is not to immediately say no,” he said.

Instead, he scours the evidence, the side effects, and the potential drug interactions that might put a patient at risk. If it seems safe for a patient to try, he gives them the green light and checks back regularly to see if it’s helping.

“It’s part of the responsibility of physicians to know what people are taking and not dismiss it, because it’s our job to know they’re going to do it safely,” he said.

One state weighs the costs of treating pain

Many dietary supplements — which don’t have to go through a regulatory review for safety or efficacy before hitting the market — are relatively cheap: Shoppers can snag 60 homeopathic arnica tablets off a drugstore shelf for less than $10.

But other alternative therapies can be costly: Craniosacral massage and acupuncture, for instance, can each run over $100 for an hourlong session, and patients may need multiple visits each month.

The Oregon Health Plan, which is the state version of Medicaid, weighed those expenses when deciding whether to cover chiropractic adjustment for lower back pain.

The chiropractic care costs more than would for a short course of opioids — a single vertebrae adjustment can cost around $65. But health officials are hopeful that they’ll save money in the long run by reducing the number of people addicted to opioids.

“We’re trying to offer up some of these treatment options from the beginning, with the goal of trying to reduce the transition from acute pain to chronic pain,” said Denise Taray, who coordinates the Oregon Pain Management Commission.

That commission spearheaded the research into what treatments should be covered and ultimately recommended that state Medicaid cover chiropractic care. They’re now looking at alternative medicine treatments for other pain conditions, such as fibromyalgia.

“We’re all focused on the opioid epidemic and managing prescribing,” said Taray. “The part that still seems to be falling through the cracks is the patient perspective and the treatment and the care of pain.”

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  • Please don’t confuse “chiropractic care” with spinal manipulation. There is some evidence that spinal manipulation, which is performed by chiropractors, osteopathic physicians, physical therapists, and some MDs, is effective for certain types of back pain, although no more effective than other treatments. “Chiropractic care” doesn’t necessarily mean the evidence-based use of spinal manipulation for back pain. It can mean the “detection” and “correction” of the chiropractic “subluxation” with an “adjustment.” Only chiropractors believe these “subluxations” or “spinal misalignments” exist, but they’ve never proven that they can reliably find them, that they have any effect on human health, or that “correcting” them is beneficial. Yet, many chiropractors will “diagnose” these “subluxations” and tell patients they need “adjustments” to benefit their allergies, asthma, ADHD, and a whole host of other conditions, plus general well-being. An evidence-based chiropractor (or PT) performing spinal manipulation may be able to help back pain, but chiropractic is so steeped in pseudoscience the medical profession is understandably reluctant to take it seriously. Yet, the American Chiropractic Association is, laughably in my opinion, promoting chiropractors as a remedy for the shortage of primary care physicians.
    As for naturopathy, please read the Naturopathic Diaries blog, written by a former practicing naturopath, who exposes the insufficiencies of their education and training and the many quack diagnoses and treatments they use.

    • Jann

      An interesting collection of comments, sounding almost as though you know of what you speak.

      According to statistics, more than 90% of all spinal adjusting/manipulation (SMT) in the US is provided by chiropractors (DCs), so your comment “Please don’t confuse ‘chiropractic care’ with spinal manipulation” leaves me scratching my head, wondering what your point is. It’s certainly not accurate.

      As for osteopathic physicians, only 2 of their US schools actually teach SMT as part of their core curriculum (and not much at that), while all the rest offer SMT classes as an “electives” (meaning more expense, and more time invested, on top of an already daunting curriculum of classes and stress). I don’t know the statistics, but I suspect that less than 5% of America’s 96,000 DOs actually adjust. So, evidently we shouldn’t confuse osteopathy with SMT either.

      Now we get to my favorite part of your commentary… about the “chiropractic subluxation”, which is one (of many) terms we use to describe “that thing” we adjust.

      This clearly identifies you as one of those “skeptics” who love to claim that DCs still believe “all disease” (LOL) is caused by “subluxations”. This also identifies you as someone who either does not actually know a chiropractor, or only knows one of a very tiny group of failed DCs (Homola for example) who love to poke at what they consider the dead carcass of our Profession.

      Hate to break it to you, but the average DC hates the term subluxation, mainly because folks like you keep throwing it in our faces. In reality, it’s just as useful a term as calling it a “fixation”, or a “somatic dysfunction”.

      Consider this: almost ALL the published chiropractic research since the 1970s was paid for by our own profession, and not by the NIH, who has funded (billions per year) to fund their medical research.

      So it’s not surprising that we have a small body of research detailing what it is we do, and why it gets the impressive results that it does. What IS amazing is how much research we actually HAVE compiled in just the last 20 years, as the barriers to publishing our research in the conventional medical journals has crumbled. As late as 1998, the maxim at every medical journal of note was that they would not publish any study by a DC unless it had negative results.

      Your last comments about the ACA promoting us as “primary care physicians” is almost accurate. According to extensive epidemiological studies published in the Lancet Journal, neuro-musculo-sketetal (NMS) complaints are actually the most common complaint to walk into a hospital or a medical office.

      If all (or even part) of that traffic was directed away from medical doctors (as economist Pran Manga suggested) and to DCs, that would solve the shortage of MDs instantly, because it would free them up from managing complaints that they have little training to address. This would also free them to address those serious diseases for which they are so brilliantly trained for. It would be a blessing for all concerned.

      Think of it like this: if all those people came to my office, I’d have pitiful little time to think about or discuss “subluxations”, and that ought to make you ecstatic.

      BTW, nothing against you personally, I just hate to read someone mouthing words they probably lifted whole cloth from one of those few skeptic “evidence-based” pseudo websites that love to troll us. I’m sure, in your heart, you meant well.

  • Chiro and Naturopathy are chalk and cheese.
    Each group should row their own boat.
    The latter must sink because it is not scientific rather mumbo jumbo.
    A chiropractic patient can immediately feel the departure of pain and immobility.

  • Despite the medical curmudgeons, the evidence not only sides with chiropractic care for the pandemic of pain, but the evidence also shows that medical spine care is a “national disaster” and is now deemed the “poster child of inefficient care” by a leading spine journal editor. Indeed, the misuse of opioids, epidural steroid injections and spine fusions based on a debunked “bad disc” diagnosis has led to this pandemic of pain and opioid abuse. I suggest these medical trolls do the research that led to the new ACP guidelines before they continue to mislead the public and their own patients as they have for decades. For more information, logon to http://www.chiropractorsforfairjournalism.com to read about the paradigm shift in spine care.

  • If scientific studies show these therapies are effective, use them. Otherwise, its just exploiting people’s pain for profit.

  • I read with amusement Ethan’s anti-quackish commentary.

    The American College of Physicians did not “grant” chiropractic anything. They reviewed thousands of studies and trials and noted the weak evidence for both conventional and alternative medicine.

    The difference between them is most interesting. Conventional medicine had been receiving 90+% of ALL the research money doled out by the NIH since its inception, whereas Alt-Med has only been receiving dribbles of grant money since the late 90s. My favorite author shared this anecdote:

    “Even more remarkable is the efficiency of chiropractic research. When compared to the NIH budget of nearly $20 billion, the $10 million investment in federal funds is substantially less than a tenth of 1 percent, which makes it less than a rounding error. Put another way, as a couple of wags have offered in the past, the federal government must believe in alternative medicine, because it has given chiropractic researchers homeopathic doses of money with which to work.”

    So, considering the mass of studies about “conventional medicine” benefits, vs. the limited number of studies about chiropractic, it is QUITE REMARKABLE that the actual evidence still puts them on a par.

    Chiropractic was legislated into the Department of Veterans Affairs system in the early 90s, but by 2000, still less than 50 DCs had been added to the VA system. This is a natural side-effect of the anti-trust activities of the AMA and other named medical groups going back almost a century, BUT it is changing.

    Many of the DCs in the military medicine system have been publishing in the peer-reviewed literature, and it is becoming more and more tenuous for trolls like Ethan to claim there is no scientific support for chiropractic.

    The term “risk-benefit ratio” is relevant: Is there a risk, and what are the benefits? The established literature suggests that chiropractic care provides similar reductions in pain to conventional approaches, and provide BETTER functional and activity-of-daily-living improvements, and much higher patient satisfaction scores. I have been collecting these supportive materials on my chiropractic website since 1995 (URL available by request). The medical alternative, which is invariably drugs, frequently followed by surgery has NOT delivered better results for the same complaints that chiropractic manages every day, at lower cost and risk.

    • Frank
      Thank you for the links. I will look at them with more care, but those I looked at are not blinded studies, nor based upon random sampling. They are convenience samples and the methods are by subjective interview. There are simple percentages of respondents, no correlation coefficients given, and while they certainly indicate a need for further study: THEY DO NOT MEET A STANDARD that would indicate they are efficacious, not better than any other treatment, including doing nothing at all. Kratom still has not been deemed a therapeutic agent by the DEA; it has considered making it a scheduled drug due to repeated reports of toxicity. It has a following of people who think it is helpful, like marijuana, but unlike marijuana, has not been studied. This is what I mean when I say that many naturopaths and chiropractitioners have no idea that simple surveys of respondents who say they have a response to something does not mean that the treatment should be suggested by a doctor, or that insurance should fund it. Some people would call these therapies quackery, I just label them under the heading of unproven.

    • Ach

      The 3rd study is a “Pragmatic Randomized Comparative Effectiveness Study”

      http://www.chiro.org/LINKS/ABSTRACTS/Adding_Chiropractic_Manipulative_Therapy.shtml

      and is the best possible way to compare standard chiropractic Tx with standard medical. This is just one of a long line of studies specifically comparing the 2 forms, as demonstrated on my Low Back and Chronic Neck Pain pages.

      http://www.chiro.org/LINKS/lowback.shtml

      http://www.chiro.org/research/ABSTRACTS/Chronic_Neck_Pain.shtml

      I am not a researcher (although I am a huge fan), I am a clinician. My hobby is collecting these materials into ordered topical pages, where it’s listed from newest to oldest. I don’t have the time to spoon feed anyone. I already did my work, gaining permissions, and rendering these materials, and arranginmg them into topical catalogs.

      If you are truly a skeptic, that means you care enough to explore. These are just 2 collection pages that sum up why chiropractic should be the first choice for neuro-musculoskeletal (NMS) complaints.

      Pran Manga, the respected Canadian economist, was hired by Canada to review our literature base, and then he informed them that DCs should become the gatekeeper in hospitals and Worker-related cases for ALL NMS injuries, because we would get better results and would save them Billions.

    • Well said, Frank, but please don’t be fooled by Jann Bellamy, she’s a chirophobic quackwatch curmudgeon who along with her husband thwarted the FSU implementation of a graduate chiro program. She is as open to anything supporting chiro care as Trump is concerning Muslim immigration. I suggest we put her and “ach” on the defensive to show us the supportive evidence for medical spine care–opioids, OTC, epidurals, and spine fusions–which is dwindling fast as the ACP guidelines suggest. The medical spine care gravy train has done more harm than anything the entire chiro profession has done over the past century in terms of cost, addictions, deaths and disability. Yet Jann and the other curmudgeons completely ignore these facts and cast aspersions at CAM providers despite the supportive evidence, guidelines, and the mass participation of Americans using CAM providers, which according to David Eisenberg, was twice that of MDs according to his 1990’s research.
      Jann is so steeped in medical bigotry–chirophobia–that she has lost all sense of credibility–she never cites studies except those of other chirophobes. Perhaps she should explain to all why the new ACP guidelines are wrong or just shut up and stop hindering the paradigm shift in spine care. As Mark Schoene, editor of The BACKLetter aptly said, “Medical spine care is the poster child of inefficient care” and has been deemed internationally as a “national disaster.”

    • Thanks JC

      I stopped following the skeptic websites after being attacked for daring to cite the literature.

      Evidently being a skeptic has nothing to do with evidence after all, it’s all about fawning on the site administrator, and garnering brownie points for pasting their comments any/everywhere, while usuallu failing even to cite the admin for their comments.

      I still give people the benefit of the doubt that they may actually care about the literature, and once in a while am pleasantly surprised.

  • Chinese medicine (including acupuncture), naturopathy, and much of chiropractic are quackery. They have no basis in biology and are unethical to sell to a patient.

    Happily, the UK-based NICE guidelines no longer recommend acupuncture and chiropractic for lower back pain. But it’s disappointing that the American College of Physicians would grant the quacks a propaganda victory as celebrated by the American Chiropractic Association.

    It’s important to mention that (according to Quackwatch) craniosacral therapy is based on absurd ideas like:
    (1) the brain makes rhythmic movements at a rate of 10 to 14 cycles per minute (2)
    diseases can be diagnosed by detecting aberrations in this rhythm, and (3) pain and many other ailments can be remedied by pressing on the skull bones.

    Quacks like naturopaths have the bizarre belief that the castor oil in castor oil packs is somehow absorbed by the body and serves as a virtual cure all. Castor oil packs are advertised for detoxification, immune system boosting, weight loss, pain, reduction in inflammation, and other implausible outcomes.

    Fake medicine also has ancillary costs, like the correlation between use of fake medicine and decrease in use of real medicine like vaccines. Shark cartilage endangers the shark population.

    As Dr. Ben Goldacre says, “Flaws in aircraft design do not prove the existence of magic carpets.”

    • “Quackwatch” is in no way a reputable source. These, however, are:
      -The Association Between Use of Chiropractic Care and Costs of Care Among Older Medicare Patients With Chronic Low Back Pain and Multiple Comorbidities
      http://www.jmptonline.org/article/S0161-4754(16)00007-5/abstract

      Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis
      http://www.thespinejournalonline.com/article/S1529-9430(03)00177-3/abstract

      A systematic review comparing the costs of chiropractic care to other interventions for spine pain in the United States
      http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-015-1140-5

      Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society
      http://annals.org/aim/article/736814/diagnosis-treatment-low-back-pain-joint-clinical-practice-guideline-from

      The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain.
      https://www.ncbi.nlm.nih.gov/pubmed/20889389

      Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: results of a pragmatic randomized comparative effectiveness study.
      https://www.ncbi.nlm.nih.gov/pubmed/?term=23060056

      Chiropractic treatment of cervical radiculopathy caused by a herniated cervical disc.
      https://www.ncbi.nlm.nih.gov/m/pubmed/8169540/

      Clinical Utilization and Cost Outcomes From an Integrative Medicine Independent Physician Association: An Additional 3-Year Update
      https://www.researchgate.net/publication/6323912_Clinical_Utilization_and_Cost_Outcomes_From_an_Integrative_Medicine_Independent_Physician_Association_An_Additional_3-Year_Update

      ODG Evidence-Based Decision Support supports the use of chiropractic:
      “A recent comprehensive meta-analysis of all clinical trials of manipulation has concluded that there was good evidence for its use in acute, sub-acute, and chronic low back pain, while the evidence for use in radiculopathy was not as strong, but still positive. (Lawrence, 2008) A Delphi consensus study based on this meta-analysis has made some recommendations regarding chiropractic treatment frequency and duration. They recommend an initial trial of 6-12 visits over a 2- to 4-week period, and, at the midway point as well as at the end of the trial, there should be a formal assessment whether the treatment is continuing to produce satisfactory clinical gains. If the criteria to support continuing chiropractic care (substantive, measurable functional gains with remaining functional deficits) have been achieved, a follow-up course of treatment may be indicated consisting of another 4-12 visits over a 2- to 4-week period. According to the study, “One of the goals of any treatment plan should be to reduce the frequency of treatments to the point where maximum therapeutic benefit continues to be achieved while encouraging more active self-therapy, such as independent strengthening and range of motion exercises, and rehabilitative exercises. Patients also need to be encouraged to return to usual activity levels despite residual pain, as well as to avoid catastrophizing and overdependence on physicians, including doctors of chiropractic.” (Globe, 2008) These recommendations are consistent with the recommendations in ODG, which suggest a trial of 6 visits, and then 12 more visits (for a total of 18) based on the results of the trial, except that the Delphi recommendations in effect incorporate two trials, with a total of up to 12 trial visits with a re-evaluation in the middle, before also continuing up to 12 more visits (for a total of up to 24). Payers may want to consider this option for patients showing continuing improvement, based on documentation at two points during the course of therapy, allowing 24 visits in total, especially if the documentation of improvement has shown that the patient has achieved or maintained RTW. This systematic review concluded that there is moderate quality evidence that spinal manipulation is effective for the treatment of acute lumbar radiculopathy, but there is no evidence for the treatment of thoracic radiculopathy. (Leininger, 2011) Based on high-quality evidence in adults with chronic low back pain, SMT vs other interventions has a small statistically significant, but not clinically relevant, short-term effect on pain relief and functional status, and referral for SMT should be based on cost considerations and patient and provider preferences. (Rubinstein, 2011) A NASS systematic review suggested that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function compared with other commonly used interventions. (Dagenais, 2010) All three interventions (manipulation, supervised exercise, and home exercise) had good outcomes in this RCT, but supervised exercise had a slight edge. (Bronfort, 2011) This RCT assessed the efficacy of spinal manipulation/mobilization (manual therapy) followed by specific active exercises and concluded that manual therapy accelerates reduced disability compared to exercise alone. (Balthazard, 2012) Osteopathic manual therapy (OMT) did well in this RCT. With 6 treatment sessions during a course of 8 weeks, 50% of the OMT group and 35% of the sham OMT group reported substantial improvement (relative risk [RR], 1.41). (Licciardone, 2013) According to this systematic review, there is a paucity of quality clinical trials testing OMT in adult patients with chronic non-specific low back pain, and more data is required. (Orrock, 2013) In patients with back-related leg pain, spinal manipulative therapy (SMT) plus home exercise and advice (HEA) provided more short-term improvement in pain and function than HEA alone. SMT plus HEA demonstrated a clinically significant advantage over HEA after 12 weeks, but not at 52 weeks. At 12 weeks, 37% of patients receiving SMT plus HEA had at least a 75% reduction in leg pain, compared with 19% in the HEA group. (Bronfort, 2014) The AHRQ draft comparative effectiveness review of noninvasive treatments for low back pain concluded that spinal manipulation was no more effective than sham manipulation, but manipulation was as effective as other interventions thought to be effective. (Chou, 2016).”

      The only professionals that pay attention to “Quackwatch” are apparently quacks.

  • ach,

    The are thousands of studies, too many too link to here, published in mainstream medical journals. You just have to look for them and read them. PubMed is a good source, and another I like for finding alternative medicine studies is Greenmedinfo.com.

    There is far too much information for anyone to assimilate and most doctors tend to go with what they know and have made money at in the past, rather than expanding their knowledge base to new solutions.

    With the opioid and heroin crisis we have, it’s time to look at some other valid options. We know what prescribing opioids does… let’s see what other solutions can do.

  • It’s about time. Opioids are not a good answer and there need to be alternatives.

    Naturopathic care can be a safe and effective choice. Mine did prolozone on my neck, back, and shoulder are a car accident, and provolone injection successfully treat my Hunters canal nerve.

    Relatively inexpensive, but highly effective. But not covered by insurance, while opioid are… I had to pay out of pocket, but I’m not an opioid addict…

    As for Dr. Briggs fears for cancer patients going rogue, I also had naturopathic care alongside conventional cancer treatment, and it was my naturopath who convinced me to do chemotherapy, saying he could help mitigate the side effects.

    I am now cancer free, and look much healthier than those who’ve just fine conventional treatments. In fact, everyone I knew who died from cancer was only doing conventional treatments without nutritional or integrative support.

    With serious health problems, we need to be open to more modalities. And I’ve been happy to find evidence based research on many “alternative” treatments that conventional doctors are woefully or willfully ignorant of.

    Outcomes matter. Let’s use naturopathic and chiropractic care to augment our arsenal of tools. They should be available to all patients, not just the well to do.

    • Im glad you did so well! Im curious about your statement that you found good quality evidence that naturopathic or alternative modalities are effective. Could you offer citations or links to these studies? The scientific evidence is surely evolving, but double blinded, peer reviewed studies are the gold standard for weighing efficacy and if those studies are in deed, well done, the links to them are important for people to see and to appreciate.

    • I’m sure the cheese your naturopath injected into your adductor canal to treat your saphenous nerve was organic and great on a turkey sandwich

    • Ach,
      I am also skeptical of many approaches that seem to be off the wall. That being said, the approach that you are proposing would bias treatment in favor of well funded companies, such as pharmaceutical companies. Pharmaceutical companies can profit by funding studies to support expensive drugs. Natural remedies are not as profitable because they cannot be patented, therefore it would not be profitable for anyone to fund such studies.

      We do know from a Washington Post/Kaiser survey that about 54% of opioid patients become addicted after using opioids for two months. That suggests that we should look for alternatives, unless the patient has cancer or a terminal case. There is also good anecdotal information that kratom is useful in treating pain and in ending opiate addiction, and there is some evidence that medical marijuana is useful for treating chronic pain.

    • Ach

      You are right that “double blinded”, “placebo-controlled” studies are the gold standard… for single substance drug trials.

      If you have ever experienced chiropractic care, you know that (1) so far no one had been able to develop a sham adjustment, and (2) you can’t blind the DC as to whether he/she gace an actual adjustment or gave a sham adjustment, so there goes double blinding out the window.

      That’s why the emphasis is shifting towards “real world” studies that compare treatment “apple” with treatment “orange”. In the long run, patients and insurers are looking for results AND cost-savings.

    • Frank,
      Spinal adjustment should be measured not only against placebo, as in watch and wait, but also standard treatments, like PT, analgesia, even surgery, etc. in order for it to be the Rx of choice, or even reimbursed, in my opinion. There really isn’t any reason why that can’t happen. And until it does your work will always be hovering around the fringes. I never discouraged patients from trying it if they had a positive attitude towards it, but I wouldn’t recommend it in the absence of anything more than subjective surveys of convenience samples, either.

  • People with chronic pain should be encouraged to explore alternatives to opioids until they get some relief, but I believe Medicare and Medicaid programs should insist on rigorous evidence before they reimburse for a lot of it. There is a lot of hokum and voodoo out there for the unknowing. That will mean that people waste money on therapies that don’t work, while missing out on treatment that has been shown to help. If you have chronic pain, see a reputable pain specialist or palliative care practitioner. Ask a lot of questions.

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