The random thoughts of a sceptical activist

What the fuss is all about

On 19 April 2008, the author and physicist Simon Singh MBE wrote an article for The Guardian newspaper on chiropractic.

This story has been told many times now by bloggers like Jack of Kent, The Lay Scientist, Skepticat and many, many others. It has also been reported worldwide and Simon’s own account can be read at Sense about Science.

But what started this all off? What was it that caused the British Chiropractic Association (BCA) to take the serious and precipitous action of personally suing Simon and which has resulted in a maelstrom of publicity for the BCA in particular and chiropractic in general.

The Guardian removed the article from their website when the BCA’s lawyers started rattling their sabres — although a copy of it is available on a Russian server, seemingly well out of reach of even English libel laws. (The World Federation of Chiropractic — of which the BCA are members — have kindly repeated the allegedly libellous words verbatim, which you can read on page 10 of their June 2009 Report).

However, to highlight the issue of the lack of evidence and dangers of chiropractic — what Simon intended his original article to do — I have reprinted a copy of that article below. No, not a direct copy. That would play too easily into others’ hands. What follows is a slightly edited version: one that is not libellous but one that spells out Simon’s original intention of highlighting the paucity of evidence for, and the very real dangers of, chiropractic.

Update: The excellent Jack of Kent has published the original allegedly libellous words on his blog so everyone can really see what the fuss is all about.

Beware the spinal trap

Some practitioners claim it is a cure-all, but the research suggests chiropractic therapy has mixed results – and can even be lethal, says Simon Singh.

You might be surprised to know that the founder of chiropractic therapy, Daniel David Palmer, wrote that “99% of all diseases are caused by displaced vertebrae”. In the 1860s, Palmer began to develop his theory that the spine was involved in almost every illness because the spinal cord connects the brain to the rest of the body. Therefore any misalignment could cause a problem in distant parts of the body.

In fact, Palmer’s first chiropractic intervention supposedly cured a man who had been profoundly deaf for 17 years. His second treatment was equally strange, because he claimed that he treated a patient with heart trouble by correcting a displaced vertebra.

You might think that modern chiropractors restrict themselves to treating back problems, but in fact some still possess quite wacky ideas. The fundamentalists argue that they can cure anything, including helping treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying – even though there is not a jot of evidence.

I can confidently label these assertions as utter nonsense because I have co-authored a book about alternative medicine with the world’s first professor of complementary medicine, Edzard Ernst. He learned chiropractic techniques himself and used them as a doctor. This is when he began to see the need for some critical evaluation. Among other projects, he examined the evidence from 70 trials exploring the benefits of chiropractic therapy in conditions unrelated to the back. He found no evidence to suggest that chiropractors could treat any such conditions.

But what about chiropractic in the context of treating back problems? Manipulating the spine can cure some problems, but results are mixed. To be fair, conventional approaches, such as physiotherapy, also struggle to treat back problems with any consistency. Nevertheless, conventional therapy is still preferable because of the serious dangers associated with chiropractic.

In 2001, a systematic review of five studies revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches. These are relatively minor effects, but the frequency is very high, and this has to be weighed against the limited benefit offered by chiropractors.

More worryingly, the hallmark technique of the chiropractor, known as high-velocity, low-amplitude thrust, carries much more significant risks. This involves pushing joints beyond their natural range of motion by applying a short, sharp force. Although this is a safe procedure for most patients, others can suffer dislocations and fractures.

Worse still, manipulation of the neck can damage the vertebral arteries, which supply blood to the brain. So-called vertebral dissection can ultimately cut off the blood supply, which in turn can lead to a stroke and even death. Because there is usually a delay between the vertebral dissection and the blockage of blood to the brain, the link between chiropractic and strokes went unnoticed for many years. Recently, however, it has been possible to identify cases where spinal manipulation has certainly been the cause of vertebral dissection.

Laurie Mathiason was a 20-year-old Canadian waitress who visited a chiropractor 21 times between 1997 and 1998 to relieve her low-back pain. On her penultimate visit she complained of stiffness in her neck. That evening she began dropping plates at the restaurant, so she returned to the chiropractor. As the chiropractor manipulated her neck, Mathiason began to cry, her eyes started to roll, she foamed at the mouth and her body began to convulse. She was rushed to hospital, slipped into a coma and died three days later. At the inquest, the coroner declared: “Laurie died of a ruptured vertebral artery, which occurred in association with a chiropractic manipulation of the neck.”

This case is not unique. In Canada alone there have been several other women who have died after receiving chiropractic therapy, and Edzard Ernst has identified about 700 cases of serious complications among the medical literature. This should be a major concern for health officials, particularly as under-reporting will mean that the actual number of cases is much higher.

If spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.

Simon Singh is a science writer in London and the co-author, with Edzard Ernst, of Trick or Treatment? Alternative Medicine on Trial.

This is an edited version of an article published in The Guardian for which Singh is being personally sued for libel by the British Chiropractic Association.

3 Responses to What the fuss is all about

  • Go on, Zeno, show us the ‘very real’ evidence for the “very real dangers of chiropractic”. Tricky really, not much about eh?

    Try instead:

    Safety of Chiropractic Manipulation of the Cervical Spine: A Prospective National Survey.
    Spine. 32(21):2375-2378, October 1, 2007.
    Thiel, Haymo W. DC, PhD *; Bolton, Jennifer E. PhD *; Docherty, Sharon PhD *; Portlock, Jane C. PhD +
    Abstract:
    Study Design. Prospective national survey.
    Objective. To estimate the risk of serious and relatively minor adverse events following chiropractic manipulation of the cervical spine by a sample of U.K. chiropractors.
    Summary of Background Data. The risk of a serious adverse event following chiropractic manipulation of the cervical spine is largely unknown. Estimates range from 1 in 200,000 to 1 in several million cervical spine manipulations.
    Methods. We studied treatment outcomes obtained from 19,722 patients. Manipulation was defined as the application of a high-velocity/low-amplitude or mechanically assisted thrust to the cervical spine. Serious adverse events, defined as “referred to hospital A&E and/or severe onset/worsening of symptoms immediately after treatment and/or resulted in persistent or significant disability/incapacity,” and minor adverse events reported by patients as a worsening of presenting symptoms or onset of new symptoms, were recorded immediately, and up to 7 days, after treatment.
    Results. Data were obtained from 28,807 treatment consultations and 50,276 cervical spine manipulations. There were no reports of serious adverse events. This translates to an estimated risk of a serious adverse event of, at worse [almost equal to]1 per 10,000 treatment consultations immediately after cervical spine manipulation, [almost equal to]2 per 10,000 treatment consultations up to 7 days after treatment and [almost equal to]6 per 100,000 cervical spine manipulations. Minor side effects with a possible neurologic involvement were more common. The highest risk immediately after treatment was fainting/dizziness/light-headedness in, at worse [almost equal to]16 per 1000 treatment consultations. Up to 7 days after treatment, these risks were headache in, at worse [almost equal to]4 per 100, numbness/tingling in upper limbs in, at worse [almost equal to]15 per 1000 and fainting/dizziness/light-headedness in, at worse [almost equal to]13 per 1000 treatment consultations.
    Conclusion. Although minor side effects following cervical spine manipulation were relatively common, the risk of a serious adverse event, immediately or up to 7 days after treatment, was low to very low.

    And
    The Bone and Joint Decade 2000 – 2010 Task Force on Neck Pain and Its Associated Disorders published its 236 page review of current research on neck pain in SPINE on the 15th Feb 2008. Led by Professor Scott Handlemann for the Uni of California. 50 researchers in 9 countries comprising of 14 different clinical disciplines. Over 31,000 research criterion were analysed and over 1000 met relevant criteria.

    The Task force recommended that neck manipulation, acupuncture and massage are better choices for managing most common neck pain. It recommended exercises, education and neck mobilization but to be less effective than adjustment. It does not recommend neck collars and ultrasound. Those who are suffering grade 3 (the minority) would befit from a corticosteroid injection to provide temp relief. Surgery must be the last resort.

    Stroke
    It has been shown that patients who visit a chiropractor are no more likely to experience stroke than those who visit a GP or doctor.

    I think it is time for some scepticism about Singh and the spin he’s placed on all this. St.Simon’s original intention was to make himself and Professor Ernst, a well known denialist, some money and I think we should stop pretending he’s doing it for any other altruistic reason. The last lines is his imbecilic business trumping-up article were these:

    “.If spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.

    Simon Singh is a science writer in London and the co-author, with Edzard Ernst, of Trick or Treatment? Alternative Medicine on Trial.”

    So, go now and buy my book, please.

  • ‘Aww Come On’ says, “I think it is time for some scepticism about Singh and the spin he’s placed on all this. St.Simon’s original intention was to make himself and Professor Ernst, a well known denialist, some money and I think we should stop pretending he’s doing it for any other altruistic reason.”

    This might have been persuasive were it not for the fact that Singh isn’t short of a few bob and has already demonstrated that he is prepared to lose hundreds of thousands of pounds on this particular crusade. I’m afraid the suggestion that his motivation is entirely mercenary just makes you look rather silly, Aww Come On (and so does your choice of username, by the way).

    Remember, this case isn’t actually about the very real dangers of chiropractic – as the 818 VBA victims in the Ontario study* would no doubt call them – it’s about Singh saying that the BCA ‘happily promotes bogus therapies for which there isn’t a jot of evidence’.

    So a more useful way of challenging this campaign, ACO, would be for you to give us the evidence for the alleged benefits of chiropractic.

    Tricky really, not much about eh?

    *Cassidy JD, Boyle B, Cote P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ. Risk of vertebro-basilar stroke and chiropractic care: results of a population based case control and case crossover study. Spine 2008 Feb 15; 33 (4 suppl): S176-83. I recommend this article:

    http://www.sciencebasedmedicine.org/?p=170#more-170

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