The random thoughts of a sceptical activist

Discover Chiropractic

No. I’ve not been converted and I’m not urging you all to realise that the future of humanity and an end to all pain, suffering and diseases known to man lies in the chiropractic way.

It’s the name of a chiropractic clinic in Edinburgh. They wanted to spread the word about the benefits of chiropractic and decided to advertise.

Oops! You’d have thought… No. I won’t say it again.

The advert

Discover Chiropractic placed an advert in the December 2009 Blackhall Bulletin, produced by Blackhall St Columba’s Church.

The advert made claims about:

  • Low back pain/disc injuries/sciatica
  • Neck pain/headaches/migraines
  • Joint stiffness & some arthritis
  • Shoulder/elbow/arm pain & numbness
  • Breathing problems/digestive troubles/abdominal pain
  • Childhood illness: colic/not sleeping/bedwetting/asthma

The magazine was passed to me and it was duly submitted to the ASA. The ASA decided to investigate the advert and one of their Investigation Executives contacted the advertiser.

The chiropractic clinic responded saying they would amend the ad. The ASA considered that:

…their assurance that they will amend the ad will resolve the complaint without referring the matter to the ASA Council.

No formal adjudication then, but they do get a mention in the list of informally resolved complaints this week.

So, is this just another chiropractor making blasé claims? Well, not quite. But it does seem that some chiropractors just are not aware of what they can and what they cannot claim.

Déjà vu

It’s as clear as it can be: the GCC’s Code of Practice clearly stipulates that they must abide by ASA guidance.

Take colic, for example. The ASA have published adjudications against chiropractors claiming they can help/treat/cure colic on three occasions:

Even the General Chiropractic Council had to agree to change two of their own leaflets as a result of separate complaints from Simon Perry. These didn’t get as far as a formal investigation, but, like Discover Chiropractic, they did get a mention in the list of informally resolved complaints. However, the GCC didn’t immediately take any action to resolve the problem with the misleading leaflets already issued.

Of course, just because these particular chiropractors didn’t — or couldn’t — supply good enough evidence to the ASA to substantiate the claims they were making doesn’t mean to say another chiropractor might not have the evidence to hand.

But you’d have thought that chiropractors who had been complained about would have tried their best to make sure the ASA didn’t uphold those complaints. Bad publicity is bad for business.

I have no idea why this particular chiropractor decided just to agree to withdraw the advert, but he was in a very good position to be able to supply that evidence — assuming it does, indeed, exist.

Although the advert only mentioned two chiropractors, there are four chiropractors at Discover Chiropractic: Glenn Caley, Torey Griswold, Rebecca Vickery and Ross McDonald. Of these, Ross McDonald is a member of the British Chiropractic Association, but they are all members of the Scottish Chiropractic Association. In fact, Ross McDonald is its President.

You’d have thought that he would have been far better placed than most to come up with the evidence to back the claims he made.

Apparently not.

No more claims

Top and left: 19 January 2010
Right: 26 January 2010

Discover Chiropractic have removed all the claims from their windows over this past week. I wonder how many other chiropractors will now remove all similar claims from their websites and advertising?

Doctor, Doctor

They were also told not to use the title Dr.

As well as featuring in the GCC’s CoP, the ASA’s guidance (which is binding on all chiropractors) on the use of the title ‘Dr’ makes it clear that chiropractors should not mislead the public by using the title:

In general, CAP advises that if they do not possess a general medical qualification advertisers should not call themselves “Dr”.

And:

…a chiropractor should not use the claim “Dr Smith (Doctor of Chiropractic)” but could claim “Mike Smith, who is a doctor of chiropractic” or similar.

Like the above claims — if the guidance wasn’t enough — there have been many ASA adjudications against chiropractors using the title ‘Dr’. For example:

But there’s more…

Much more.

As you can see from the advert, the chiropractors also made the claims that:

Chiropractic care improves the function of your spine and nervous system…

That is, of course, the main tenet of chiropractic. The GCC define chiropractic as:

Chiropractic is concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system and the effects of these disorders on the function of the nervous system and general health.  There is an emphasis on manual treatments including spinal manipulation or adjustment (World Federation of Chiropractic, 1999).

The British Chiropractic Association claims:

Chiropractors treat problems with joints, bones and muscles, and the effects they have on the nervous system. Working on all the joints of the body, concentrating particularly on the spine, they use their hands to make often gentle, specific adjustments (the chiropractic word for manipulation) to improve the efficiency of the nervous system and release the body’s natural healing ability.

The Scottish Chiropractic Association claims:

Chiropractic concerns itself with the relationship between structure (primarily the spine) and function (primarily coordinated by the nervous system) of the human body, and how that relationship affects the restoration and preservation of health.

The SCA go on to say:

The Focus of Chiropractic Care is on the Integrity of Your Nervous System

Sometimes vertebrae can become misaligned or fixated causing interference with the mental impulses that travel between the brain and the rest of the body. Chiropractors refer to this as a vertebral subluxation. A subluxation can cause pain, imbalance, fatigue, lowered resistance to disease and a general decline in health.

Doctors of Chiropractic specialise in locating and then correcting vertebral subluxations with a chiropractic spinal adjustment permitting normal nerve transmission, innate recuperative capability, and effective health and adaptation of the person.

That chiropractic can improve the spine and nervous system — whether or not they shun the dreaded ‘subluxation’ word — is a universally held belief amongst chiropractors and central to their practice. Although there is no good independent evidence for the existence of subluxations — and some evidence that they don’t exist and do not have any effect on nerve function — there can be little doubt that, without such beliefs, chiropractic does not have a leg to stand on.

It is difficult to imagine how you could describe chiropractic without claiming it improves spine and nerve function.

So what would happen if these claims were undermined by, say, the ASA declaring that such claims have not been substantiated?

That is exactly what the ASA have said.

In my complaint, I doubted that the advertiser could justify the claims that chiropractic could improve the function of the spine and nervous system. The ASA have told me that they expect the advertiser to remove all the claims about conditions, serious or otherwise, not on their approved list and that:

This also applies to the claim that chiropractic is able to improve the function of the spine and nervous system, so we would expect the advertisers to also remove this claim.

A claim about improving the function of the spine or nervous system is treated just like a claim about colic or asthma: they are not on the list, therefore they are not allowed.

However, this is not something new or a new interpretation of their guidance:

…this has been the CAP/ASA position for some time.  It is based on substantiation we have seen from the Chiropractic community, independent expert advice and previous adjudications.

A chiropractor making such a claim would be contrary to ASA guidance — and this has been the case for some time. And since ASA guidance forms an integral part of the GCC’s Code of Practice, it would seem that chiropractors are in a bit of a pickle.

Where do chiropractors go from here?

Well, they could try to persuade the ASA that they can, indeed, improve the function of the spine and nervous system. But the evidence for that is pretty thin on the ground and certainly currently not up to the ASA’s standard.

What they do meantime is for them to decide.

Discover Chiropractic

To find our more about chiropractic, visit the new Discover Chiropractic website, launched today. Although in its infancy, it will be built up as a resource of scientific and evidential information about chiropractic.

Prof. Edzard Ernst said this of the new website:

I think it is high time that the public learns the truth about chiropractic. Independent, impartial information was previously very hard to come by and the chiropractic profession has been shown over and over again to make unsubstantiated claims. This has the potential to cause serious harm and it is important that this stops.

Prof. Edzard Ernst, MD, PhD, FMed Sci, FSB, FRCP, FRCP (Edin.)
Complementary Medicine
Peninsula Medical School
Exeter

121 Responses to Discover Chiropractic

  • I believe Edinburgh Trading Standards have “evidence” that chiropractic works…

    They may well be the target of future Edinburgh Skeptics actions…

  • Some fantastic work here. Very well done. Keep it up.

  • Excellent work, as usual.

    I can’t help but notice that their sign seems to have a subluxation. Perhaps this is the real cause of their problems?

  • Love the new site (not sure if you’re responsible for it). It’s a bit like the various “vaccination advice” sites except this one uses actual evidence rather than conspiracy theory.

    My only concern is the link list. There’s no doubting the effect bloggers such as yourself have had and continue to have but, for the most part, they don’t come across as “quality” references in my opinion. Linking to mostly-generic sceptical blogs gives the site away I think. I’d be tempted to stick with Cochrane, BMJ and similar resources if possible – or create a separate site that pools some of the best works from these blog sources then link to that.

    I’ll blog a link to it soon – FWIW.

  • I’d like to echo AndyD’s comments. In the interests of impartiality there should be at least a link to the GCC, especially as said council is referred to several times in the FAQs. Without such links it really isn’t impartial at all.

  • Thanks for all the comments on the new site – I’ll take them on board.

    As I said, it’s in its infancy (I designed it and set it up on Sunday and added content on Monday and Tuesday evenings!), so there is a lot more tweaking to be done!

  • In fact, if you want to be impartial, why not divide the links page into sections.

    (1) The evidence and links to ‘sound’ sites (as suggested by AndyD). Include the GCC in this perhaps? (possible moral dilemma)
    (2) Links to useful sceptical/scientific blogs. Try to avoid over use on big names such as DC, which might put off people who are sitting on the fence.
    (3) Links to less-bonkers pro-chiropractic sites. (Possibly a better home for the GCC link)

    Keep tweaking. It’s a good start on a potentially brilliant resource.

  • I agree with AndyD about the links. Although my blog is one of them, I think including links to the home pages of skeptic blogs is a step too far in the direction of bias and away from objectivity.

    I suggest just having ‘scholarly’ links. There could be a separate heading for recommended articles from different blogs but I don’t think there should just be links to blogs regardless of whether they are big names or not.

  • It’s an excellent site – i look forward to seein it develop. Would you plan to update it with the results of relevant medical studies?

  • Its a pity the Golden Rule doesn’t apply to some.

  • I agree that the links are biased. If you are linking out to anecdotes of harm caused by chiropractors, then surely you should also link out to anecdotes of success stories too.

    Of course, you’re entitled to do what you want to do.

    Disclaimer – I am pro chiropractic.

  • @Jeremy

    If the stories of harm are backed by medical reports and coroners reports – and they generally are – then they cease to be just anecdotes and become evidence.

    The same would hold true of any success stories, of course.

  • @fed up

    Can you clarify what you mean by that?

  • @Skepticat

    Sure, I have no problems with that, however the websites linked to seem to have the case studies with an absence of medical reports.

    To me that seems a case of double standards.

    “I agree with AndyD about the links. Although my blog is one of them, I think including links to the home pages of skeptic blogs is a step too far in the direction of bias and away from objectivity.”

    The way I interpret your comment above is a disguised admission of bias on your own blog. And obviously that is fine, you are entitled to your opinions. However, Zeno’s website is intended to maintain a neutral stance on the evidence for and against chiropractic. To maintain a set of links to case studies of harm caused by chiropractic without verifiable evidence and to omit success stories of chiropractic also without verifiable evidence, is definitely biased.

    Like I say, that is fine, however DiscoverChiropractic.co.uk cannot then pretend to maintain a neutral stance on the subject.

    I think that is fair to say.

  • There’s nothing ‘disguised’ about my admission, Jeremy. Of course my blog is biased – all blogs are. I’m a skeptic and that’s the perspective I write from.

    My main reservation about the inclusion of personal blogs in the links page is that, whichever way they are biased, they are opinions and arguments and thus distinct from the objective evidence to be found on Cochrane etc. I notice that many quacks – homeopaths, usually – aren’t able to distinguish between actual reports of clinical studies and the way their results are subsequently presented in a zillion homeopathist websites whose authors – unlike me – feel no obligation to reference and, if possible link directly to their sources. I would like to see the new website set a good example and link only to scholarly sources.

    That said, were Zeno to prefer to include other links, I think having links to relevant blog posts, in a separate section that is clearly labelled as such would be OK. And by ‘relevant’, I mean posts that help to fulfil the website’s stated objective, which is to “provide information about the scientific and evidence base for chiropractic,” in order to redress the balance of information provided on the web “because chiropractic clinic websites…are not always as impartial as they could be.” (my bold)

    Who said the Discover Chiropractic evidence is “intended to maintain a neutral stance” because it says nothing of the kind on the website itself?

  • Let me rephrase from using the word neutral to the description he put forward. In light of that, perhaps he should change the description to

    “provide biased information about the scientific evidence base for chiropractic”

    Whatever way you wish to argue, the fact is clear. The website does not provide the full range of scientific and evidence base for chiropractic.

    Linking out to anonymous stories of harm caused by chiropractors (with names withheld), is NOT scientific, is NOT evidence based and Zeno CANNOT pretend that this website is providing information as such.

    When a “woo” advocate references to a patient testimonial of health improvement from their particular discipline, this is labelled as an anecodote and unscientific.

    However when biased skeptics do the exact same, the story is taken as scientific fact.

    Double standards. What a joke.

  • “The website does not provide the full range of scientific and evidence base for chiropractic.”

    Give him a chance. The website’s only been up a few days and it makes it clear that it’s a work in progress. If you know of some good scientific evidence that isn’t referenced on the website, why not provide the references to him?

    “Linking out to anonymous stories of harm caused by chiropractors (with names withheld), is NOT scientific, is NOT evidence based and Zeno CANNOT pretend that this website is providing information as such.”

    I would agree if there were, indeed, links directly to anonymous stories of harm. But there aren’t. There a number of links to chiropractic victims’ websites and a few of those victims are anonymous. Most are not. One way round the problem would, of course, be not to have links victims’ websites. But then he wouldn’t be redressing the balance of information put out by chiropractors, which only ever feature success stories. Another way round the problem would be to directly link only to those stories that contain the full name and details of the victim.

    “When a “woo” advocate references to a patient testimonial of health improvement from their particular discipline, this is labelled as an anecodote and unscientific.

    However when biased skeptics do the exact same, the story is taken as scientific fact.”

    I refer you to my first answer above. If someone suffers an injury and medical opinion confirms that the injury was probably or certainly caused by a therapy the victim had undergone, then that ceases to be just an anecdote and becomes medical evidence. The majority of victims whose stories are featured on those websites assert that they have such evidence. It’s not a case of people just saying “Wow, I’ve been so much better (worse) since I had that therapy.” It’s a case of people being independently examined and being able to say that, according to medical opinion, they had been damaged by a therapy.

    “Double standards. What a joke.”

    Pots and kettles spring to mind. There are thousands and thousands of chiropractic websites that never breathe a word about all the chiropractic failures but feature second-hand patient testimonials as if they were the epitome of objective evidence. Yet you come huffing and puffing about one little website that aims to tell the other side of the story.

    That’s what I’d call a double standard.

  • By, the way, are you the same Jeremy I have to thank for inspiring this blog post?

    http://www.skepticat.org/2009/10/chiropractic-is-crap/

  • @skepticat

    Good attempt at manoeuvring around the real issue. A website that prides itself on “providing information about the scientific and evidence base for chiropractic” that links to anecdotal stories is definitely not providing scientific evidence. Unless of course the requirements from skeptics for evidence has changed?

    By the way I noticed on your blog a comment on the left hand side

    “Skepticat is just another rent a mouth anti CAM medic with time on her hands and a prescription pad.”
    Richard Lanigan

    However on Richard Lanigans blog I notice the comment to be

    “Skepticat is perfectly entitled to his opinion, why he thinks Hariet Hall should be such an expert on chiropractic or the anatomy and physiology of the spine, is beyond me. She is just another rent a mouth anti CAM medic with time on her hands and a prescription pad.”

    Either your name is Harriet and you like to talk about yourself in the third person, or you just randomly modify other bloggers comments, and make them your own….

    Interesting.

  • Jeremy,

    There is no ‘manouvering’ on my part. I’ve said it straight twice and I’ll say it one more time:

    patient or quack testimonial = anecdote

    patient testimonial supported by independent medical or coroners report = evidence

    I don’t believe that you are so blinkered that you cannot grasp this very simple point but, in any event, I am giving up on it. Carry on bleating sanctimoniously about this one website that aims to tell the truth and ignore all the spin of the zillion others. If I were a quack trying to defend the indefensible, that’s exactly what I’d do too.

    By the way, you are right about Lanigan’s comment. I misread it and thought he was saying I was the rent a mouth. I’ll remove it from my quackolades. Thanks for the heads up.

  • @skepticat

    http://www.chirovictims.org.uk/victims/Ms%20LK%20-%20Case%20study.htm

    http://www.chirovictims.org.uk/victims/Miss%20H.htm

    I see no independent medical or coroners report and I am sure there are more. Therefore DiscoverChiropractic.co.uk is not providing scientific and evidence based information which it purports to do.

    Big time FAIL.

  • @skepticat

    Oh and yes, that is me to thank. I’m flattered that my opinions mean so much to you ;-)

    I would like to know where the original comment was made. You mention it was on your blog, however I don’t actually recall writing it on your blog.

    Then again, perhaps I am mistaken? It was a while ago now.

  • @skepticat
    “patient testimonial supported by independent medical or coroners report = evidence” – oh no no no… this is not evidence, this is their opinion.

    Whilst a patient may have had an injury following a visit to a chiropractor/osteopath/physiotherapist (as reported in many “victims” sites) it does not mean that the practitioner actually caused the injury, especially a condition such as a stroke. This is because one of the most commonly presenting symptoms of a vertebral artery tear (for which manipulation is often blamed) is neck pain and headaches, conditions that are in themselves common due to benign musculoskeletal dysfunction.

    It simply means that the practitioner missed the signs of the early onset of the arterial tear, which is terrible for the person involved but it does not mean that it was caused by the practitioner. It has been shown time and again that this is just as likely to happen had the patient presented to their G.P.

    I have seen incidence of chiropractors being blamed for causing a stroke in a patient who had had treatment for a low back complaint some six months earlier and had never had their neck manipulated. The patient set the medic straight immediately.

    I have had G.P.’s refer patients for treatment for neck pain and headaches and following examination it was identified that they actually had a cardiovascular condition or were suffering an “event” that required urgent referral. The medic did not cause the event, but they missed it. Had a chiropractor/osteopath/physio missed it they would have been accused of causing it.

    So as this condition may happen spontaneously it is just as likely to have happened had they attended their G.P’s practice as they had been to McDonalds

    God bless you

    Interested in the truth

  • I see no independent medical or coroners report and I am sure there are more. Therefore DiscoverChiropractic.co.uk is not providing scientific and evidence based information which it purports to do.

    Big time FAIL.

    I’m getting a sense of deja vu. As I said in my earlier post, most of the stories on those websites are people who have independent confirmation by doctors that the injuries were probably caused by chiropractic. What would you have zeno do? Directly link only to the ones that are supported? No, of course you wouldn’t. You don’t want him to link to those sites at all. You just want him to shut up. That’s all this is about, isn’t it, Jeremy? ‘By all means publicise those who believe chiropractic helped them but those who have independent expert opinion that chiropractic has hurt them should be muzzled – so stfu, zeno!’

    None of those stories are even on the DiscoverChiropractic.co.uk so citing them as proof that DC isn’t providing scientific evidence etc. is a bit weak, frankly. You’ve got a whole website there and you focus on objecting to a couple of the links?

    Re my blog – your original comment was the last one below this post.

    http://www.skepticat.org/2009/04/lesley-regans-medicine-cabinet/

    @ Uninterested in the truth:

    “patient testimonial supported by independent medical or coroners report = evidence” – oh no no no… this is not evidence, this is their opinion.

    It is expert opinion based on ALL the available evidence. Crikey, why are you chiros so desperate to shut critics up?

  • Interested in the truth wrote: “Whilst a patient may have had an injury following a visit to a chiropractor/osteopath/physiotherapist (as reported in many “victims” sites) it does not mean that the practitioner actually caused the injury, especially a condition such as a stroke. This is because one of the most commonly presenting symptoms of a vertebral artery tear (for which manipulation is often blamed) is neck pain and headaches, conditions that are in themselves common due to benign musculoskeletal dysfunction.”

    But according to the GCC:
    “UK chiropractors are trained in differential diagnosis and are required to refer urgently patients presenting with symptoms of stroke onset to the appropriate health professionals”
    http://www.chiropractor-help.co.uk/chiropractic/chiropractors/downloads/gcc-letter-to-daily-mail-6oct08.pdf

    It begs the question, just how competent are chiropractors at detecting strokes in progress? And perhaps more importantly, considering that other therapeutic options (e.g. exercise therapy or massage) have not been associated with significant risks at all, why do chiropractors routinely administer neck manipulations? Surely such an intervention would, in most cases, be contraindicated by a responsible risk/benefit assessment?

  • @ Scepticat
    “It is expert opinion based on ALL the available evidence. Crikey, why are you chiros so desperate to shut critics up?”

    Exactly, it is “opinion” and the only evidence available is a tear in an artery, which may have occurred for various reasons, commonly spontaneously. Which is why many people have strokes without ever having had any form of manipulation.

    And I was not trying to shut critics up, just trying to shed light on what happens in the clinical world on a daily basis.

    I am sorry that you took this view on my comments.

    There is no need for silly unhelpful comments such as “uninterested in the truth”.

    @ Blue Wode

    “It begs the question, just how competent are chiropractors at detecting strokes in progress?”

    I am sorry that you have misinterpreted my comments. My point was that the presentation of an arterial tear in its early stages can be and is missed by medics, hospital consultants, a&e, chiropractors, osteopaths, physiotherapists etc. alike. It does not mean that they caused the event (with or without treatment).

    So we could start asking how competent any of these practitioners are at detecting this event. Which, goes on to address the issue of treatment i.e. that it is not necessarily always the cause of the event.

  • Interested in the truth said that treatment “is not necessarily *always* the cause of the event”.

    One has to conclude from that that you agree that on some occasions the treatment *is* the cause of the stroke event – in which case it shouldn’t have been administered in the first place when there are safer and equally effective interventions available.

  • I’m sorry that I’m a bit late to the party but I’ve only just caught up with this.

    I’m a chiropractor of some 25 years experience and I’d like to share a story with you.

    About 17 years ago, a 32 year old woman presented to me complaining of neck pain and headache. I won’t go into the whole history here, suffice to say that the nature of the symptoms and their onset, together with family history, past medical history and lifestyle features, led me to refer her to A&E. Unfortunately, when she was examined at A&E she was diagnosed with a migraine and discharged with analgesics.

    Next day she came to see me again, desperate for help with her pain. This time I referred her to her GP whom I telephoned to express my concerns. Unfortunately, the GP was typically dismissive but I believe that the patient went to see him anyway, as a result of my insistence to her.

    I’m not sure of the exact course of events that followed but I tried to contact the patient over the next couple of days and eventually spoke to her mother. Her mother told me that the patient had been admitted to hospital and had been diagnosed with a stroke. I contacted the hospital and spoke to the neurologist managing her who confirmed the situation. Tragically, the conclusion of the story is that the patient went on to suffer a further, larger stroke and died in the next few days.

    Thankfully, I had not treated this woman but this is the sort of event that results in chiropractors being blamed for causing strokes. If the medics who examined her at the critical time had made the correct diagnosis, she MAY have been saved.

    What it goes to show, I suppose, is that everyone is fallible…………..

  • David wrote: “I had not treated this woman but this is the sort of event that results in chiropractors being blamed for causing strokes. If the medics who examined her at the critical time had made the correct diagnosis, she MAY have been saved. What it goes to show, I suppose, is that everyone is fallible…”

    That may be so, but it still doesn’t excuse chiropractors who cause strokes in patients who are asymptomatic.

    Surely it cannot be anything other than unethical for chiropractors to diagnose fictitious chiropractic ‘subluxations’ in patients’ cervical spines and go on to ‘adjust’ them with a procedure that is known to carry a risk of serious injury or death?

    Similarly, for those chiropractors who do manage to identify genuine problems in patients’ cervical spines, it cannot be anything other than unethical for them to administer neck manipulations when there are currently equally effective, but safer, options available.

  • Blue Wode wrote: “….it still doesn’t excuse chiropractors who cause strokes in patients who are asymptomatic.”

    The evidence that chiropractors cause strokes AT ALL is circumstantial. The numbers are tiny, and the probability that the strokes that subjects have suffered are a direct result of a chiropractic adjustment is very low.
    I have yet to see genuine proof that a properly administered chiropractic adjustment, delivered to a completely asymptomatic patient has been the direct cause of a stroke.

    As we know, the presenting symptoms are often neck pain and headache and it is up to the practitioner to spot the diagnosis. The truth is that strokes are misdiagnosed by “proper” doctors much more frequently than by chiropractors and my example is a case in point.

    Blue Wode wrote: “Surely it cannot be anything other than unethical for chiropractors to diagnose fictitious chiropractic ‘subluxations’ in patients’ cervical spines and go on to ‘adjust’ them………”

    Personally, I do not, and never have, used the term subluxation in my work, other than in the context that you would find in Dorland’s Medical Dictionary. However, I do treat patients for dysfunction of the neuromusculoskeletal system.

    There is nothing fictitious about these problems and, although I choose not to use the term subluxation, it is used by some of my colleagues as a phrase to encapsulate the concept of an area of dysfunction. I don’t believe that it is an appropriate term but the concept that it descibes is certainly not fiction. Dysfunction of the neuromusculoskeletal system exists and these are the problems that chiropractors aim to help. You can argue about how much dysfunction an individual has and about how this is affecting them. However, you can not argue that it never exists at all.

    Blue Wode wrote: “….it cannot be anything other than unethical for them to administer neck manipulations when there are currently equally effective, but safer, options available.”

    The trouble is that other options are NOT as effective. However, the good news is that chiropractic is in fact a very safe, as well as effective option.

  • One hardly knows where to begin. Bias against chiropractic is the natural result of understanding anatomy and physiology, and the central tenet of chiro- the subluxation. Chiros who avoid that term merely substitute another name for that fictional entity and carry on as if nothing has happened.

    There is no legitimate, scientific evidence supporting chiro except for possibly being as effective for low back pain as other treatments (e.g., massage). When chiros offer evidence for anything else they cite unscientific articles in their own magazines, or manipulation performed by non-chiros.

    The fact that chiro neck-manipulations cause strokes is not in doubt (except by chiros); the bilateral artery dissection is chiro’s unique contribution to healthcare. The question is how frequently it occurs, and that is unknown since many stroke victims never are able to communicate.

    There is a further consideration related to the strokes, and that is there is no known benefit from neck manipulation to justify the risk. On top of that, chiros manipulate the necks of people with no symptoms in that area.

    The safety and efficacy of chiropractic is in doubt, and a subluxation by any other name smells as bad.

  • JJM wrote: “Bias against chiropractic is the natural result of understanding anatomy and physiology…”

    Rubbish. When one has a better understanding of the anatomy and neurophysiology, one begins to understand how chiropractic can produce the effects that are seen. It is the neurophysiology research (not the chiropractic research) that confirms the ability to affect central nervous function, and therefore output to the motor and autonomic systems, through the alteration of mechanoreceptor input. Unfortunately, it is ignorance on behalf of the skeptics that persuades them to dismiss chiropractic, simply because they actually don’t understand it.

    JJM wrote: “There is no legitimate, scientific evidence supporting chiro except for possibly being as effective for low back pain as other treatments….”

    Rubbish. The research shows that even manipulation alone is as effective at treating back pain as other treatments. Of course chiropractic involves so much more than manipulation, incorporating the exercise protocols and management of lifestyle and psychosocial factors that are proven to affect the long-term outlook of sufferers.

    JJM wrote: “The fact that chiro neck-manipulations cause strokes is not in doubt”

    Yes it is.

    JJM wrote: “…chiros manipulate the necks of people with no symptoms in that area.”

    Chiropractors employ tried and tested methods to safely and effectively treat their patients. The biomechanical disorders that chiropractors manage often only become symptomatic when they have progressed beyond a certain point. You could liken it to angina, in that the victim only becomes aware of the problem once it has developed far enough. To wait until symptoms arrive is illogical; it makes sense to deal with problems as soon as they are detected, not wait until they are symptomatic.

    JJM wrote: “The safety and efficacy of chiropractic is in doubt, and a subluxation by any other name smells as bad.”

    Only if you are one of those that allows themselves to be led by the naysayers.

  • David wrote, “It is the neurophysiology research (not the chiropractic research) that confirms the ability to affect central nervous function, and therefore output to the motor and autonomic systems, through the alteration of mechanoreceptor input.”

    This is interesting, if rather difficult to follow. What do you mean by ‘mechanoreceptor input’ and how do you alter it? Which mechanorepectors are you refering to? Can you provide any references to this neurophysiology research that I might be able to look up?

  • David,

    http://www.ptjournal.org/cgi/content/full/79/1/50 [This article reviews 177 reports of injury following neck manipulation. Chiropractors are responsible for 60-70% of injuries, PTs are responsible for 2%. An explanation for the discrepancy, offered elsewhere, is that PTs are both more selective and more skillful than chiros. They also note “The literature does not demonstrate that the benefits of MCS outweigh the risks.”]

    http://www.neurology.org/cgi/content/abstract/60/9/1424 Conclusions: This case-controlled study of the influence of SMT and cervical arterial dissection shows that SMT is independently associated with vertebral arterial dissection, even after controlling for neck pain.

    Siva K. Talluri et al The American Journal of Medicine, Vol 122, No 11, November 2009 An estimated 18 million people annually visit chiropractors for treatment of neck pain.1 Spinal manipulative therapy is a frequently applied therapy for back and neck pain. Carotid and vertebral artery trauma, cerebellar and brainstem stroke, fracture of odontoid process, and atlantoaxial dislocation due to chiropractic manipulation have been reported in the literature. We report an occurrence of quadriparesis after chiropractic manipulation.

    Maurizio Paciaroni and Julien Bogousslavsky Eur Neurol 2009;61:112–118 Abstract The safety of spinal manipulation is an issue that demands regular and rigorous assessment, as manipulation of the upper spine has been associated with serious adverse events such as cerebrovascular accidents due to cervical artery dissection. A correlation between stroke and cervical manipulation has been reported with increasing frequency, and each new report seems to reignite debate between neurologists and manual therapists.

    U. Reuter et al J Neurol Published online: 6 March 2006 DOI 10.1007/s00415-006-0099-x In summary, we describe the clinical pattern of 36 patients with vertebral artery dissections and prior chiropractic neck manipulation.

    http://www.skepticreport.com/health/strokespinal.htm [leading references to the dangers and inutility of chiropractic neck manipulation.]

    Adverse Effects of Chiropractic http://www.sciencebasedmedicine.org/?p=509

    Chiropractic and Stroke: Evaluation of One Paper http://www.sciencebasedmedicine.org/?p=170

    Anatomy of chiro-stroke http://www.quackwatch.org/01QuackeryRelatedTopics/chirostroke.html

    http://stroke.ahajournals.org/cgi/content/full/32/5/1054 Conclusions—While our analysis is consistent with a positive association in young adults, potential sources of bias are also discussed. The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment. Because of the popularity of spinal manipulation, high-quality research on both its risks and benefits is recommended.

    http://www.jrsm.org/cgi/content/full/99/4/192 Conclusions: Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.

    E Ernst J R Soc Med 2007;100:330–338 Conclusions: Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissection followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.

    http://www.sciencebasedmedicine.org/?p=3022 [There is no evidence for the existence of the chiropractic subluxation. I will add that re-naming it does not create it. Chiros who do not say “subluxation” provide the same useless services as those who do.]

  • @Artemis: Monday 01 February 2010 at 22:24

    David wrote, “It is the neurophysiology research (not the chiropractic research) that confirms the ability to affect central nervous function …”

    Let me translate that for you. “Basic research in neurology has been coopted by chiros, without clinical trials as evidence, to support chiropractic flights of fantasy.”

  • @ JJM

    Where does one start?

    I’m afraid that your first reference proves nothing. The author (a physiotherapist trying to prove a point), admits that the study is flawed in so many ways. Firstly, he’s trying to analyse cases from as far back as 1925! Secondly, he admits that an unknown number of cases have been attributed to chiropractors when it actually wasn’t a chiropractor involved. Thirdly, the study includes an unknown number of duplicated cases. Fourthly, the prior medical history is unknown in most of the cases. Fifthly, he’s relying on someone else’s translation of a number of the papers because the original was written in a foreign language. Sixthly, he is unable to determine the type of manipulation involved in the majority of cases. Seventhly, he acknowledges the unreliability of a retrospective study. The flaws are endless. What he does do is cite a couple of prospective studies that have been done, neither of which has shown any serious side effects of spinal manipulation at all.

    Of course, in none of the cases included in this study has it been PROVED that a properly administered chiropractic adjustment has been entirely responsible for a stroke. As my experience shows, patients sometimes present to chiropractors with the symptoms of a vertebral artery dissection. Thankfully, in my case I avoided treating the patient because I recognised the signs. It’s sad to say that the patient’s death could well be attributable to the incompetence/negligence/pig-headedness of the medics that I referred her to.

    Frankly, it’s ludicrous to suggeest that PTs are as skilled, let alone more so, than chiropractors in their manipulative skills.

    In your second reference, again there is no EVIDENCE that chiropractors have been responsible for any of these events. What the statistics show is that a percentage of the subjects had had some manipulation within the thirty days prior to the event. As we know, people seek the help of chiropractors when they are suffering neck pain and headaches because they know that chiropractors are the specialists in managing those conditions. Sadly, these can also be the symptoms of a vertebral artery dissection in progress. THe poor old chiropractor then gets blamed for the “injury” when it’s true nature becomes apparent.

    Basically, the same goes for the rest of your references. Shouting the same thing again and again doesn’t make it any more true than it was initially.

    As previously noted, prospective studies are the best for analyising the truth of the situation and universally none of them has shown any serious side effects of chiropractic manipulation. Have a look at this one where over 50,000 neck manipulations were followed up and none was found to have caused any serious sided effects. http://www.ncbi.nlm.nih.gov/pubmed/17906581

    When it comes to anything written by Edzard Ernst, I’m afraid that he blew his credibility as an objective commentator on chiropractic issues long ago. He is well known for cherry-picking his data and then presenting them in the most negative light possible.

    As for subluxations, you really do need to get away from the idea that chiropractic is concerned only with clearing subluxations. As I say, I haven’t ever used that term, or any equivalent, when describing neuromusculoskeletal problems to patients. The language and concepts we use are exactly the same as those used in orthopaedics, neurology, rehabilitation etc. Insisting that today’s chiropractic is concerned only with the subluxation is like insisting that today’s medicine is concerned only with blood-letting.

  • @ Artemis

    THank you for your interest. Mechanoreceptors are nerve endings that sense movement, stretch and pressure. They exist throughout the body including the cardiovascular system, the skin and the gut. However, there is also a type of mechanoreceptor called a proprioceptor that exists in the joints and muscles. These feed information into the spinal cord and brain and are used principally for keeping us informed about where we are in space, thus allowing us to remain stable and to accurately co-ordinate movement. If you stand still with your feet together, eyes closed and try to touch the end of your nose with your index finger, you are relying on proprioception to remain standing and to co-ordinate the muscles necessary to complete the task.

    Anyway, your question was what research is there to show that joint mecanoreceptors affect central activity and/or efferent nerve flow. Here are some references that spring to mind.

    http://www.ncbi.nlm.nih.gov/pubmed/17137836
    http://www.manualtherapyjournal.com/article/S1356-689X(08)00020-9/abstract
    http://www.journals.elsevierhealth.com/periodicals/clinph/article/PIIS1388245703001317/abstract
    http://www.ncbi.nlm.nih.gov/pubmed/10706436
    http://www.ncbi.nlm.nih.gov/pubmed/19913058

    Ignore the accusation by JJM that chiropractors “coopt” neurological research. What chiropractors do is “incorporate” research into their work and that’s called practising “evidence-based medicine”.

  • David wrote: “As previously noted, prospective studies are the best for analysing the truth of the situation and universally none of them has shown any serious side effects of chiropractic manipulation. Have a look at this one where over 50,000 neck manipulations were followed up and none was found to have caused any serious sided effects.”

    Here’s what Ernst had to say about that study:

    Quote
    “The sample of this survey was sizeable but not large enough to exclude rare events…The picture gets more complicated when considering the 698 treatment consultations of patients who failed to return for their next treatment. Theoretically some or most or all of these patients could have died of a stroke. Overlooking even one single serious adverse event would change the estimated incidence rates from this study quite dramatically. In my view, the most confusing aspect about the results of this survey is the fact that the incidence of minor adverse events is so low. Previous studies have repeatedly shown it to be around 50%. The discrepancy requires an explanation. There could be several but mine goes as follows: the participating chiropractors were highly self-selected. Thus they were sufficiently experienced to select low-risk patients (in violation of the protocol). This explains the low rate of minor adverse events and begs the question whether the incidence of serious adverse events is reliable.”
    [Ref. Ernst, E. Focus Altern Complement Ther 2008; 13: 41–2]

    It’s also interesting to note that HW Thiel and JE Bolton, in their authors’ response to the study, estimated of the number of neck manipulations carried out in a year by chiropractors in the UK as being 4 million – an estimate that seemed to double in under 6 months, given their previous estimate of over 2 million in the BMJ. That can only leave them open to accusations that they may be trying to play down the risks.

    David wrote: “When it comes to anything written by Edzard Ernst, I’m afraid that he blew his credibility as an objective commentator on chiropractic issues long ago. He is well known for cherry-picking his data and then presenting them in the most negative light possible.”

    What reasons might a career scientist like Edzard Ernst (a professor of complementary medicine who has received training in spinal manipulation) have to be biased, and what reasons might you, a chiropractor, have?

    David wrote: “As for subluxations, you really do need to get away from the idea that chiropractic is concerned only with clearing subluxations. As I say, I haven’t ever used that term, or any equivalent, when describing neuromusculoskeletal problems to patients. The language and concepts we use are exactly the same as those used in orthopaedics, neurology, rehabilitation etc.”

    Then you are not practicing ‘chiropractic’, but a form of physiotherapy.

    David wrote: “Insisting that today’s chiropractic is concerned only with the subluxation is like insisting that today’s medicine is concerned only with blood-letting.”

    Nonsense. In a 2007 survey, 76% of UK chiropractors deemed traditional chiropractic beliefs (chiropractic philosophy) to be important to their practices and the same survey gave a figure of 63% for chiropractors who still considered the fictitious ‘subluxation’ lesion to be central to chiropractic intervention. (And those were the ones who were willing to admit it.)
    [Ref. Aranka Pollentier and Jennifer M. Langworthy, The scope of chiropractic practice: A survey of chiropractors in the UK. Clinical Chiropractic, Volume 10, Issue 3, Pages 147-155. September 2007]

  • David wrote “Of course, in none of the cases included in this study has it been PROVED that a properly administered chiropractic adjustment has been entirely responsible for a stroke.”

    No matter whatever else you dodge around with- the fact that the author collected all the reports that he could and found that chiros cause more than 60% of the harm, and PTs around 2%, means that chiros are going about it wrong.

    As for your citation to the safety of chiro, I can only see the abstract. First, we know serious damage is rare we just don’t know how rare. If they lost even one person to follow-up it would significantly change their calculations. Also, since the neck snap serves no purpose, the risk/benefit ratio is way too high.

    Your first study is not clinical, it is tiny and only “suggests” a result. It does not mention chiropractic.
    Looks like #2 concerns PT, not chiro, and it also just suggestive.
    The third is not about chiro.
    Likewise #4 and #5.

    So, just as I said, you have incorporated terminology with no proof of the ability of chiros to ‘clinically’ achieve any associated effects.

    The American Association of Chiropractic Colleges says the core of chiropractic is finding and correcting subluxations. If you are not doing that you are not working as a chiropractor. The fact is, there is nothing to chiro (except, perhaps, treatment of low back pain) that is known to be safe and effective.

  • Blue Wode wrote: “What reasons might a career scientist like Edzard Ernst (a professor of complementary medicine who has received training in spinal manipulation) have to be biased”

    Good question. However, there’s no doubt that he is biased. Whether it’s a personal issue I don’t know (did his wife run off with a chiropractor or some such?) What we do know though is that he is enjoying the proceeds from the book that he wrote with Simon Singh and is going to such lengths to defend. There is simply no way that Ernst can be considered as an independent or objective source of opinion on chiropractic.

    Blue Wode wrote: “Then you are not practicing ‘chiropractic’, but a form of physiotherapy”

    Today’s chiropractic is a sophisticated system of managing musculoskeletal health problems. My chiropractic career began over 25 years ago and has NEVER featured the “subluxation” as Blue Wode and JJM insist it must. It’s obviously very inconvenient that the image of chiropractic that they wish to present is so far from the reality.

    The survey that Blue Wode quotes is not a good one to draw a judgement from as there was a low number of respondents and the predominance of McTimoney chiropractors included who I’m afraid do tend to hang on to the out-dated beliefs of old. As the authors note “Statistically significant differences between chiropractors of different associations in the UK were present, particularly regarding the benefits of chiropractic treatment for non-musculoskeletal conditions.”

  • JJM wrote: “No matter whatever else you dodge around with- the fact that the author collected all the reports that he could and found that chiros cause more than 60% of the harm, and PTs around 2%, means that chiros are going about it wrong.”

    Given that the author was unable to establish which profession all of the practitioners belonged to, the figures are unreliable. Also, a further, massive flaw in this study is that the author has made the assumption that ALL chiropractic interventions have included manipulation and there is no evidence that they did. THe physiotherapy cases included were only ones where the PT RECORDED having used manipulation as opposed to mobilization. So, we don’t know how many cases there might have been as a result of mobilization, which the author considers to be safer rather than manipulation. These are not reliable figures.

    THe references I gave were deliberately not chiropractic references. The point is that the mechanisms by which mechanical stimulation of the afferent pathways affects central function and therefore efferent outflow are not a chiropractic “flight of fancy”, but sound neurophysiological principles.

  • @ JJM

    JJM wrote: “No matter whatever else you dodge around with- the fact that the author collected all the reports that he could and found that chiros cause more than 60% of the harm, and PTs around 2%, means that chiros are going about it wrong.”

    Of course, this study still doesn’t prove that a chiropractor did any harm at all. All it shows is that these poor people had some event within a thirty day period of having seen either a chiropractor or a physiotherapist. What we don’t know is whether they were already suffering the event before their visit or whether it happened some time after. It is not proven that it happened as a result of the treatment received by the chiro or physio.

  • David’s statement that the PT paper included any problem within 30 days of manipulation; but he has it confused with another paper. The PT paper was based on reports of problems that were associated with neck manipulation. There are plenty more reports of people having a stroke on the chiro “table” or minutes thereafter.

    David’s statement that the PT study was limited to “manipulation” as opposed to (gentler) “mobilization” used by PTs. Wrong again, the search was for papers with the terms: “chiropractic,” “cervical vertebrae,” “neck pain,” and “physical therapy.”

    Basically, David is clawing for straws (and missing).

    David wrote “THe references I gave were deliberately not chiropractic references.” Well, go ahead and provide some reliable evidence that chiros can produce a significant clinical benefit based on that research. Keep in mind, that we need good evidence, not some chiro twaddle (which is what one finds in “refereed” chiro magazines).

  • David, as you haven’t answered my question satisfactorily, I am putting it to you again: “What *reasons* might a career scientist like Edzard Ernst (a professor of complementary medicine who has received training in spinal manipulation) have to be biased, and what reasons might YOU, a chiropractor, have? Please note that citing a book that Ernst co-authored with Simon Singh on the (lack of) scientific evidence for CAM therapies does not count as bias since it was wholly factual.

    David wrote: “Today’s chiropractic is a sophisticated system of managing musculoskeletal health problems.”

    Then one can only apply the “misleading people by sophistry” definition to your use of the word ‘sophisticated’ (a sophist being a person who reasons with clever but fallacious arguments).

    David wrote: “The survey that Blue Wode quotes is not a good one to draw a judgement from as there was a low number of respondents and the predominance of McTimoney chiropractors included who I’m afraid do tend to hang on to the out-dated beliefs of old.”

    As you are aware, McTimoney chiropractors make up over a quarter of all UK chiropractors. Considering that chiropractors have been regulated by statute in the UK since 2001, and that their code of ethics requires that all chiropractors’ provision of care *must* be evidence based, why haven’t your regulators put a stop to these “out-dated beliefs of old”. Whose side are they on – chiropractors or patients?

    For any readers wishing to read the facts about chiropractic practices in the UK, which in my opinion the General Chiropractic Council should be publishing, please click on this link:
    http://www.discoverchiropractic.co.uk/?page_id=8

  • @JJM

    The author of your study states: “Several limitations were encountered when analyzing data for this article. Published cases were difficult to find….. there were large blocks of data (eg, health history prior to incident, type of manipulation used) that were not reported in the published studies. For some articles originally published in foreign languages, only incomplete data were available because the author of the secondary analysis did not extract all of the information needed in the present review. The use of ambiguous terminology or labels that possibly misrepresented practitioners was also a factor that complicated the extraction of data from case reports and the randomized controlled trials that addressed MCS. For example, “chiropractic manipulation” was not always done by a chiropractor, or patient outcomes were compared for physical therapy versus manual therapy (when manual therapy is practiced by physical therapists).

    So, an admission that the study is actually mostly conjecture.

    Anyway, you can mix up any of the retrospective studies and still come to the same conclusion; they don’t actually prove anything. For real proof you need prospective studies and thankfully we’ve got a very good one that was published in Spine.

    As you may be aware, Spine is internationally recognised as the leading journal in its field, “not some chiro twaddle (which is what one finds in “refereed” chiro magazines)” as YOU might say. In there you will find the largest prospective study yet undertaken: http://www.ncbi.nlm.nih.gov/pubmed/17906581
    Interestingly, there are no reports of serious side effects of chiropractic manipulation of the neck in over 50,000 sessions.

    Of course, the detractors from chiropractic will try to find fault in any study that shows positive results. However, even the lofty Edzard Ernst had trouble finding negative comment to make. The best he could do was to express surprise at how few adverse effects there were, and then to cast aspersions on the integrity of the authors. I think that the editors of the world’s most respected journal on spinal matters are better placed than a proven cynic like Ernst to comment on the merits of the paper.

    The reason I supplied you with non-chiropractic references was precisely because of the sort of comment you made about chiropractic research. You have absolutely no reason to doubt the validity, integrity or quality of chiropractic research, however you will inevitably dismiss it because of your evident prejudice.

  • Blue Wode wrote: ““What *reasons* might a career scientist like Edzard Ernst (a professor of complementary medicine who has received training in spinal manipulation) have to be biased, and what reasons might YOU, a chiropractor, have?”

    It is a mystery why Ernst takes the position he does, but noone can reasonably argue that he is objective and unbiased. The fact that he co-authored a book with the title “Trick or Treatment” gives a fair clue as to his starting point. Wherever he startd from in his campaign, his efforts now are concentrated on being enerringly negative, whatever the circumstance of evidence before him.

    I couldn’t claim to be unbiased but the stance I take is through knowledge and experience, not the wish to attract attention by being pugnacious.

    “Sophisticated” – Altered by education, experience, etc., so as to be worldly-wise; not naive.

    “Sophisticated” – Complex or intricate, as a system or process.

  • @David

    “It is a mystery why Ernst takes the position he does”

    Is it really a mystery? Perhaps he is actually following the evidence, although I see you seem to be claiming to be doing that as well.

    “but noone can reasonably argue that he is objective and unbiased.”

    Why not? You’ve not offered any evidence for this opinion and the rest of your paragraph continues the ad hominem. Can you see that your statements about him could easily be turned round to apply to anyone who makes a living out of chiropractic? They’d be biased, wouldn’t they? The whole point of science is to remove that bias, whether deliberate or not and from wherever it comes. And from what I can see, science wins and chiropractic loses.

    Instead of irrelevant and unnecessary personal attacks, can you focus on the problem of chiropractic and why you think the evidence Ernst and others present might be wrong? There are also a lot of unanswered or half-answered questions from JJM, Blue Wode and Artemis.

  • David wrote: “It is a mystery why Ernst takes the position he does, but noone can reasonably argue that he is objective and unbiased…Wherever he startd from in his campaign, his efforts now are concentrated on being enerringly negative, whatever the circumstance of evidence before him.”

    David, that is completely untrue. Here he is with a list of his positive findings (registration free):
    http://www.pulsetoday.co.uk/story.asp?sectioncode=20&storycode=4123323&c=1

  • Blue Wode wrote: “David, that is completely untrue. Here he is with a list of his positive findings”

    Well there you go! No mention of chiropractic at all when even Ernst’s own studies have shown chiropractic to be effective in the management of back pain, neck pain and headaches. Yet he can’t bring himself to acknowledge it.

    That’s called prejudice.

  • @David

    Now you’ve completely confused me. You say Ernst is biased against chiropractic, but in the next post you say “Ernst’s own studies have shown chiropractic to be effective in the management of back pain, neck pain and headaches.”

    Which is it? Or do you just accept his research when it supports chiropractic?

  • @Joe

    When Ernst did his “systematic review of systematic reviews” of spinal manipulation research, he set his criteria so as to exclude the most positive papers and in fact referred largely to his own previous work.

    However, the net he cast still produced studies that showed chiropractic to be helpful in the management of back pain, neck pain, dizziness and headaches, although you’d never know it if you were to read only the conclusion, let alone the abstract.

    http://jrsm.rsmjournals.com/cgi/content/full/99/4/192?ijkey=c452b5318509f5cfe415e23c1a20e7a4173b70b8

    Bear in mind when you do read it that he also specifically excluded studies that utilised anything more than just manipulation, thereby excluding virtually any study that might i
    consider the whole chiropractic package.

    You see, this is his trademark. Carefully select your “evidence” and then put as negative and alarmist slant on it as you think you can get away with.

  • I’m all for carefully selecting evidence: get rid of the flawed ones so they don’t taint the good ones. Perfectly sound practice.

    However, you do now seem to be (grudgingly) accepting that Ernst has said something positive about chiropractic, so do you still assert that he is biased and not objective?

  • @ Joe

    As you say, selecting the evidence so that you weed out the bad stuff is sensible. Selecting your evidence in order to exclude the good stuff that counters your intended message is prejudiced.

    There’s nothing grudging about my raising the subject of Ernst’s so-called systematic review. My point is that even though it revealed positive evidence for chiropractic, Ernst did his best to conceal that fact in his analysis.

    Then, when he’s brought out of his ivory tower to defend himself against accusations of being unremittingly negative, he gives a list of occasions when he claims he has been positive. However, he has notably excluded chiropractic from that list even though he should have included it, on the basis that his research has shown it to be effective.

    That smacks of prejudice to me and, dare I say it, dishonesty.

  • @David

    You appear to be making the accusation that Ernst selected his evidence in order to exclude the good stuff that counters your intended message.

    Do you have evidence that Ernst selected trials with that intention?

  • @David: Friday 05 February 2010 at 16:21 “As you may be aware, Spine is internationally recognised as the leading journal in its field …”

    The reputation of the journal does matter, publication is just the start of the discussion. BTW, Spine’s reputation is so low among serious medical types that it is not available in my University library, or any other nearby. Spine credulously publishes too much chiro twaddle.

    @David: Friday 05 February 2010 at 16:21 “The reason I supplied you with non-chiropractic references was precisely because of the sort of comment you made about chiropractic research.”

    More to the point, you cannot find any reliable proof that chiros can use anything more than the “terminology” of science to support their work. I’ll give you another chance to point us to the reliable, clinical research that shows how chiro has been shown to work based on those principles.

  • David wrote: “No mention of chiropractic at all when even Ernst’s own studies have shown chiropractic to be effective in the management of back pain, neck pain and headaches. Yet he can’t bring himself to acknowledge it.”

    Have you ever considered that the reason he can’t promote it is because of its overall unfavourable risk/benefit profile?
    http://www.ukskeptics.com/documents/spinal_manipulation_benefits_risks.pdf

    David wrote: “When Ernst did his “systematic review of systematic reviews” of spinal manipulation research, he set his criteria so as to exclude the most positive papers and in fact referred largely to his own previous work.”

    Here’s Ernst and Canter’s response to their critics of that paper:

    QUOTE
    “We are, of course, flattered by this amount of interest in our article (1) and would like to respond as follows to the multitude of interesting arguments. Spinal manipulation was first described in 1895 by the `magnetic healer’ D D Palmer as a treatment of `subluxations’ of the spine and other joints. Early chiropractors believed that `subluxations’ were the cause of all diseases—to quote Palmer: `95% of all diseases are caused by displaced vertebrae, the remainder by luxations of other joints’.(2) Today, 89.8% of (USA) chiropractors feel that spinal manipulation should not be limited to musculoskeletal conditions.(3)
    It is thus not `methodologically unsound’, as D Byfield and P McCarthy assume, but necessary to conduct a health technology assessment of spinal manipulations for the full range of conditions for which adequate data are available. Similarly, global assessments exist also in the chiropractic literature and are acclaimed by chiropractors—as long as they are not truly critical of their practice.(4)
    Of course, Byfield and McCarthy are right, the majority of chiropractic patients suffer from musculoskeletal problems, but are they suggesting one must not ask questions about the rest? And, of course, the `straight’ chiropractors adhering to Palmer’s gospel are in the minority; but, in the UK, the influence of those `vitalists’, who insist spinal manipulation is a panacea, is growing.(5)
    It is not correct that we have `aggregated’ different conditions. In fact, we assessed systematic reviews pertaining to different conditions quite separately.(1) A systematic review is an accepted method for minimizing bias, the argument that our article maximized bias seems therefore illogical and has no basis. In this context it is worth noting that most of the commentators are affiliated with chiropractic or osteopathic organizations, while neither of us is on the payroll of an interested party. Byfield and McCarthy’s claim that our approach `lacks statistical validity’ is embarrassing—we did not use any statistics in this paper.
    Systematic reviews inevitably require some inclusion/exclusion criteria. Thus, some articles will always be omitted which others would have liked to include—perhaps because of their favourable results. It is, however, misleading to imply that we systematically excluded studies of `manipulation as used in practice’. Most of the 16 evaluated reviews included such trials.
    B J Lewis and G Carruthers are mistaken when stating that four of the systematic reviews included were `reviews of reviews’. In fact, they all were reviews of controlled clinical trials. Similarly, it is disingenuous to imply that we merely evaluated reviews of our `own opinion’. The fact that four of the 16 included articles were our own simply shows that we are research-active in this area. To exclude one’s own work in systematic reviews would be woefully unscientific.
    Several comments note that our conclusions are not in line with current guidelines. We also make this point in our article and suggest `… that these guideline be reconsidered in the light of the best available data’.(1) Surely this is sensible? Yet Breen et al. categorically state `… there is enough evidence about manipulation in the back pain area’, providing no reference in support of this statement. One could therefore be forgiven for concluding that it is more the result of wishful thinking than of critical evaluation.”
    http://jrsm.rsmjournals.com/cgi/content/full/99/6/279

    Seems like a pretty sound defence to me.

  • @ David: Are you going to supply citations to reliable, clinical, chiropractic data that supports your claim that chiro is supported by scientific research? Bear in mind, that you claim the ability to treat many problems, so your citations must cover each one. (You can omit the low back pain- for our purposes I will concede that.)

  • @ Blue Wode

    In Ernst’s response to criticism of his bias against chiropractic, he states: “Well chaps, here it comes: a list of treatments that my research has determined to be effective or at least promising on the basis of the totality of the available trial data.”

    In his list he includes the likes of aromatherapy for cancer prevention but still can’t bring himself to admit that there is good evidence for chiropractic for ANYTHING, even though he knows perfectly well that his own research has produced evidence for the management of back pain, neck pain, dizziness an headaches.

    That’s called bias.

  • @ JJM

    I think you’re getting a bit carried away, my friend. I have not made any claims that I “can treat many problems”.

    You’ve missed the point. What I said was that there is research in the non-chiropractic literature that describes the mechanism by which altering mechanoreceptor afferentation can affect central processes and efferent function. This is not a contentious issue, it is well understood by anyone with a passing knowledge of neurology. I even supplied you with a few references.

    The reason I gave you non-chiropractic references is because, as you have subsequently proved, I suspected that you would try to dismiss, out of hand, any research published in the chiropractic literature. There are masses of chiropractic references I can give you, but I’m sure that you’re plenty capable enough of finding those for yourself. What I’m not going to do is start dissecting and defending every paper that we could consider, I don’t have the time.

  • @David, sometimes Ernst adds new data and changes his position- scientists reject earlier ideas as more information is acquired, chiropractors just re-name them (subluxation …). In the case of chiro, his latest position is: “Conclusions: Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.” http://www.jrsm.org/cgi/content/full/99/4/192

    David writes “I have not made any claims that I “can treat many problems”.” That is standard chiropractic, semantic weaseling. They somehow feel that implied claims are less testable than overt claims. Not so. If people in trouble come to you and you do anything in response, “treatment” is implied, the outcome can be measured.

    Finally, the reason that David does not furnish citations to legitimate literature is because he knows there are none. One wonders if he has seen the BCA’s plethora of evidence for treatment of childhood ailments. I think that chiros have learned that it is better to withhold evidence and be thought a fool rather than provide it and remove all doubt.

  • David wrote: “In Ernst’s response to criticism of his bias against chiropractic, he states: “Well chaps, here it comes: a list of treatments that my research has determined to be effective or at least promising on the basis of the totality of the available trial data.” In his list he includes the likes of aromatherapy for cancer prevention but still can’t bring himself to admit that there is good evidence for chiropractic for ANYTHING, even though he knows perfectly well that his own research has produced evidence for the management of back pain, neck pain, dizziness an headaches. That’s called bias.”

    And that’s what I call a cautious attitude. As I’ve already said, it is my understanding that he cannot promote chiropractic as a therapeutic intervention for any indication because of its overall unfavourable risk/benefit profile. For example, the following is lifted from his recent criticism of the inclusion of spinal manipulation by chiropractors in the new NICE guidelines for acute low back pain:

    QUOTE
    “The risk of mild to moderate adverse effects is undisputed even by chiropractors: about 50%(!) of all patients suffer from such adverse effect after spinal manipulations (10). These effects (mostly local or referred pain) are usually gone after 1–2 days but, considering the very moderate benefit, they might already be enough to tilt the risk-benefit balance in the wrong direction. In addition, several hundred (I estimate 700) cases are on record of dramatic complications after spinal manipulation. Most frequently they are because of vertebral arterial dissection (5). Considering these adverse events, the risk-benefit balance would almost certainly fail to be positive. It is true, however, that the evidence as to a causal relationship is not entirely uniform. Yet applying the cautionary principle, one ought to err on the safe side and view these complications at least as possibly caused by spinal manipulations. So why were these risks not considered more seriously? The guideline gives the following reason: ‘The review focussed on evidence relevant to the treatment of low back pain, hence cervical manipulation was outside our inclusion criteria’. It is true that serious complications occur mostly (not exclusively) after upper spinal manipulation. So the guideline authors felt that they could be excluded. This assumes that a patient with lower back pain will not receive manipulations of the upper spine. This is clearly not always the case.
    Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.”
    http://www.ingentaconnect.com/content/bsc/ijcp/2009/00000063/00000010/art00006;jsessionid=1sei3p6k6go3s.victoria
    Ref: Ernst, E. Spinal manipulation for the early management of persistent non-specific low back pain – a critique of the recent NICE guidelines. Int J Clin Prac, Vol 63, No10, Oct 2009, pp.1419-1420

  • @ JJM

    You wrote: “scientists reject earlier ideas as more information is acquired, chiropractors just re-name them (subluxation …)….”

    You are precisely right, approaches do adapt and develop as knowledge is acquired. In the case of chiroprcatic as I have known it over the last quarter century, things have changed a lot and we remain at the forefront of musculoskeletal care.

    The simplistic “subluxation” concept had already been ditched when I first got involved and I have never used the term. Others may continue to use it, but I suspect that that is for the sake of simplicity when explaining concepts to the lay person. To suggest that the whole of today’s chiropractic consists only of dealing with your definition of “subluxations” is frankly ludicrous.

    What we’re seeing here JJM, is you desperately trying to claim some sort of victory over this issue. You’re convincing yourself that you’ve backed me into a corner, suggesting that I’ve made claims that I can’t substantiate. Sorry mate, but you haven’t.

  • @ Blue Wode

    Here we go again. Your quote is yet another example of Ernst playing down the benefits as much as he can and playing up the tiniest negative that he can find in order to be as alarmist and destructive as possible. My case gets stronger every time.

    And once again, chiropractic, certainly for the massive majority of UK trained chiropractors, is not about “subluxations”, no matter how many times you try to claim that it is.

  • @David

    I note you haven’t responded to my last comment.

    However, a quick Google search (“subluxation chiropractic clinic site:.co.uk”) gives 774 hits. Hardly scientific or comprehensive, but it gives a decent indication that the word is in general usage by UK chiros.

    I doubt that, as you suggest, it is used as a simplification for something the lay person wouldn’t understand, but perhaps you could give us a clear description of what you think a subluxation is a proxy term for?

  • David, even if the risk/benefit profile for chiropractic spinal manipulation for back pain was favourable, it is still no better than cheaper and more convenient options as highlighted by the most up to date Cochrane systematic review on the subject:

    QUOTE:
    “This review of 39 trials found that spinal manipulation was more effective in reducing pain and improving the ability to perform everyday activities than sham (fake) therapy and therapies already known to be unhelpful. However, it was no more or less effective than medication for pain, physical therapy, exercises, back school or the care given by a general practitioner.”
    http://www.cochrane.org/reviews/en/ab000447.html

    If more people knew the truth about chiropractic, my guess is that we would see its fairly swift demise.

  • @BlueWode

    “If more people knew the truth about chiropractic, my guess is that we would see its fairly swift demise.”

    Errrr. You have got to be kidding me. That is one of the most laughable comments I have ever seen. Skeptics have been trying to fight Chiropractic since its inception and failed miserably each and every time.

    If everyone had the same beliefs about health and healing as biased skeptics, then of course you’ve got a shot. But they don’t. In fact, I would say you are a shrinking minority.

  • @ Blue Wode

    “…the most up to date Cochrane systematic review on the subject” was compiled using data gathered up until January 2000 and therefore excludes the likes of the UK BEAM trial. Also, the Cochrane review is not a comment on chiropractic at all, only about a third of the studies looked at involved chiropractors.

    Blue Wode wrote: “If more people knew the truth about chiropractic, my guess is that we would see its fairly swift demise.”

    In the twenty odd years I have been practicing, my patients have come to me by recommendation by existing, satisfied patients, many of whom have tried other approaches before coming to see me. Others have been referred by GPs, consultants, physiotherapists, dentists. A small number come purely as a result of the reputation of chiropractic, but that represents a very small minority. We never advertise.

    It seems to me that it would please you greatly to see the demise of chiropractic which suggests that your intentions here are purely malicious. It’s a shame that you have such a coloured view. I wonder, have you ever consulted a chiropractor?

  • @ Joe

    Remind me, what was your last comment?

    You wrote: “I doubt that, as you suggest, it is used as a simplification for something the lay person wouldn’t understand, but perhaps you could give us a clear description of what you think a subluxation is a proxy term for?”

    I’m only going to say this one more time. I do not, and never have, used the term subluxation in the manner described and I am not about to get drawn into an argument about a term that I don’t use.

  • In response to the final remark I made in my last post, Jeremy wrote: “Errrr. You have got to be kidding me. That is one of the most laughable comments I have ever seen. Skeptics have been trying to fight Chiropractic since its inception and failed miserably each and every time. If everyone had the same beliefs about health and healing as biased skeptics, then of course you’ve got a shot. But they don’t. In fact, I would say you are a shrinking minority.”

    Are you sure about that, Jeremy? Chiropractic owes its growth largely to relentless marketing and political lobbying. In other words, chiropractors have managed to dupe legislators and the public, both of whom are generally not well-versed in scientific matters. However, chiropractic’s future is not looking as bright as you might think. For example, there was a 39% drop in chiropractic education student enrolment in the US from 1969-2002, and while the use of CAM in general has increased there, the largest decrease has occurred for chiropractic – 9.9% down to 7.4%.

    Ref. The Future of Chiropractic Revisited: 2005 to 2015 Report & Online Poll
    http://www.altfutures.com/poll.asp

    Further, respected veteran chiropractor, Samuel Homola, points out the following:

    QUOTE
    “As I warned in ‘Bonesetting, Chiropractic and Cultism’, if chiropractic fails to specialize in an appropriate manner, there may be no justification for the existence of chiropractic when there are an adequate number of physical therapists providing manipulative therapy. Many physical therapists are now using manipulation/mobilization techniques. Of the 209 physical therapy programs in the US, 111 now offer Doctor of Physical Therapy (DPT)
    degrees… Physical therapy, by 2020, will be provided by physical therapists who are doctors of physical therapy and who may be board-certified specialists.”

    Ref. Can Chiropractors and Evidence Based Manual Therapists Work Together? The Journal of Manual & Manipulative Therapy, Vol.14 No.2 (2006) E14-E18
    http://jmmtonline.com/documents/HomolaV14N2E.pdf

    I would also venture that one of the main reasons that the BCA decided to sue Simon Singh was to silence him from making any further comments in the mainstream media that could have a negative impact on chiropractors. For example, in a recent book that he co-authored with Professor Edzard Ernst, he proposed that all chiropractors be compelled by law to disclose the following to their patients about chiropractic prior to treatment:

    QUOTE
    “WARNING: This treatment carries the risk of stroke or death if spinal manipulation is applied to the neck. Elsewhere on the spine, chiropractic therapy is relatively safe. It has shown some evidence of benefit in the treatment of back pain, but conventional treatments are usually equally effective and much cheaper. In the treatment of all other conditions, chiropractic therapy is ineffective except that it might act as a placebo.”

    Ref. Trick or Treatment? Alternative Medicine on Trial; p.285

    Of course, if chiropractors were to tell patients that, it’s likely that it would deter most of them from proceeding with treatment. No doubt it was with that concern in mind that the British Chiropractic Association managed to have the Daily Telegraph remove an article entitled ‘Chiropractors are a waste time’ from its website in November 2007. See page 7 here:
    http://www.gcc-uk.org/files/page_file/WEBSITE_GCCNews23.pdf

  • @ David

    I think you are well aware of the problems with the BEAM trial:

    QUOTE:
    “Three brief comments on the excellent BEAM Trial (1). My reading of the results is that the data are compatible with a non-specific effect caused by touch: exercise has a significantly positive effect on back pain which can be enhanced by touch. If this “devil’s advocate” view is correct, the effects have little to do with spinal manipulation per se.

    It would be relevant to know which of the three professional groups (chiropractors, osteopaths, physiotherapists) generated the largest effect size. This might significantly influence the referral pattern. A post-hoc analysis might answer this question.

    It is regrettable that the study only monitored serious adverse effects. There is compelling data to demonstrate that minor adverse effects occur in about 50% of patients after spinal manipulation (2). If that is the case, such adverse events might also influence GP’s referrals.

    E Ernst, Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth

    References

    1. UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ, doi:10.1136/bmj.38282.669225.AE. BMJ 2004;19 November:1-8.

    2. Stevinson C, Ernst E. Risks associated with spinal manipulation. Am J Med 2002;112:566-70. ”

    http://www.bmj.com/cgi/eletters/bmj.38282.669225.AEv1#88126

    The BEAM trial also neglected to address the huge problem of the ‘bait and switch’ of chiropractic:
    http://www.dcscience.net/?p=1516

    The rest of your post is a mix of argumentum ad verecundiam and argumentum ad populum.

    Let’s have your scientific data.

  • @David

    You said (Monday 08 February 2010 at 23:10): “Remind me, what was your last comment?”

    I linked to it (Friday 05 February 2010 at 21:18) in my last comment, but here it is again in its entirety:

    @David

    You appear to be making the accusation that Ernst selected his evidence in order to exclude the good stuff that counters your intended message.

    Do you have evidence that Ernst selected trials with that intention?

    You also said (Monday 08 February 2010 at 23:10):

    I’m only going to say this one more time. I do not, and never have, used the term subluxation in the manner described and I am not about to get drawn into an argument about a term that I don’t use.

    I never said you did use the term, but you did say (Monday 08 February 2010 at 13:17):

    The simplistic “subluxation” concept had already been ditched when I first got involved and I have never used the term. Others may continue to use it, but I suspect that that is for the sake of simplicity when explaining concepts to the lay person.

    I provided some quick evidence that many chiros are still using the ‘s’ word. Now, I have no idea whether they are using for the sake of simplicity or not so I can’t tell if its ‘old’ meaning has been ditched, but I asked, if it was being used to explain something too complicated for mere mortals to understand, if you could explain what it was intended to represent. Can you oblige?

  • Blue Wode said: “I would also venture that one of the main reasons that the BCA decided to sue Simon Singh was to silence him from making any further comments in the mainstream media that could have a negative impact on chiropractors.”

    No, the BCA took Simon Singh to task because he made an untrue, defamatory statement about the actions of the BCA. which he then refused to retract.

    Blue Wode said: “the British Chiropractic Association managed to have the Daily Telegraph remove an article entitled ‘Chiropractors are a waste time’ from its website in November 2007.”

    Correct. And the reason that the article was removed was because the research that had been reported on had nothing to do with chiropractic. It was the journalist who took it upon themselves to suggest that chiropractors were involved in the study. In fact, what the study showed was that a group of physiotherapists in Australia had failed to be effective in treating a group of back pain patients by using their version of manipulation. There were no chiropractors involved and the techniques used were not chiropractic techniques. Therefore, the article was removed.

    Blue Wode wrote: “…..in a recent book that he [Simon singh] co-authored with Professor Edzard Ernst, he proposed that all chiropractors be compelled by law to disclose the following to their patients about chiropractic prior to treatment:……” Blah, blah, blah…..

    Here we go again, trotting out the same old exaggeration about the risks of chiropractic. Let’s be clear, the risk of serious adverse effects from chiropractic are miniscule. They are measured in terms of cases per MILLIONS of treatments.

    Added to which, as I have shown through my own experience, cases of stroke have been attributed to chiropractors when in fact chiropractors were not the cause. There is considerable doubt whether any chiropractor has, indisputably ever directly caused a patient to suffer a stroke.

    Sadly, strokes happen. The population group that has been suggested is most at risk, is the group that unfortunately is probably going to suffer a stroke anyway. Indeed, they may well have presented themselves to a chiropractor because they were already suffering the early symptoms of a stroke.

    To suggest that chiropractors should, by law, make such a ridiculous statement as that proposed by Singh and Ernst, is just plain daft.

    Risk factors for vertebral artery dissection include Yoga, painting ceilings, blowing one’s nose, having a backwash at the hairdressers, straining at stool and any number of other everyday activitites. By your criteria we would be adding warnings to everything from a haircut to tins of emulsion, handkerchiefs and lavatories!

    As you know, the opinion that Singh and Ernst offered on chiropractic in their book was typically negative and alarmist. On the basis of the information available to them, they could just as easily come to the conclusion that:

    “Chiropractic is a tried and tested treatment for which there is good evidence, especially in the management of neck pain, back pain and headaches. It’s effectiveness compares favourably with other treatments and, although concerns have been raised about the safety of manipulation of the neck, the risks of serious side effects have been shown to be somewhere in the region of 1 in 2,000,000.”

    However, that wouldn’t fit with the apparent mischievous intent of the authors, or “Blue Wode”.

  • @ Blue Wode

    You said: “I think you are well aware of the problems with the BEAM trial”

    The problem with the BEAM trial is that you can’t bear the fact that it produced positive results for the style of practice employed by the vast majority of chiropractors in the UK.

    So, you have tried to dismiss the results by suggesting that it’s touch, rather than manipulation that might have been effective! Then, just in case people spot how ridiculous that argument is, you have tried to muddy the waters by suggesting that it might not be the chiropractors who produced the benefit, but other manipulating practitioners.

    Yo would look more credible if you could actually bring yourself to admit that chiropractic has some benefits.

  • @ Joe

    You said: “You appear to be making the accusation that Ernst selected his evidence in order to exclude the good stuff that counters your intended message.

    Do you have evidence that Ernst selected trials with that intention?”

    No, of course I don’t have evidence. He doesn’t ring me up before he publishes something and tell me that he’s going to show off his bias again. What I do is read his offerings in the light of my knowledge and experience and draw reasonable conclusions.

    Let me ask you: Do you have any evidence that Ernst has NOT selected trials with that intention?

    You asked: “..if it [the term subluxation] was being used to explain something too complicated for mere mortals to understand,… could you explain what it was intended to represent”

    As I’ve said, I’m not going to get into an argument about a term that I don’t use. However, here are a couple of examples of definitions that some chiropractors use:

    “A motion segment in which alignment, movement integrity, and/or physiologic function are altered, although contact between joint surfaces remains intact.”

    “Dysfunction of a motion segment that incorporates the complex interaction of pathologic changes in nerve, muscle, ligamentous, vascular, and connective tissue.”

    Again, I’m not going to get drawn on the finer points of it all. I don’t like the term and I don’t use it.

    I prefer to explaiin to patients the particular features of their indvidual problems, using terms that they can easily understand. However, sometimes these explanations can become quite involved because they can be quite complex problems. Generally, patients like simple concepts that they can hold onto and there are times when overly simplistic terms help them to do this.

    I have endless patients who consult me saying that their GP sent them along because they had a “slipped disc” or a “trapped nerve”. I don’t get all agitated and give the GP a hard time for diagnosing such “imaginary” concepts. I understand that the GP has used the term bacuse it is a concept, albeit an inaccuarte one, that the patient can get their head round.

  • @David

    @ Joe

    You said: “You appear to be making the accusation that Ernst selected his evidence in order to exclude the good stuff that counters your intended message.

    Do you have evidence that Ernst selected trials with that intention?”

    No, of course I don’t have evidence. He doesn’t ring me up before he publishes something and tell me that he’s going to show off his bias again. What I do is read his offerings in the light of my knowledge and experience and draw reasonable conclusions.

    Can you tell me if you’re in the habit of making possibly defamatory assertions without having evidence to back them up?

    I don’t suppose that you’ve ever bothered to seriously consider that it may not be Ernst who is biased?

    Do you apply the same intellectual rigour to all your assertions?

  • @ Joe

    Are you suggesting that I’m biased? Of course I’m biased, I know the truth about the way that I practice and the concepts and techniques I use. However, that doesn’t stop me using reason to come to my judgements.

    I quite happily admit that chiropractic doesn’t have ALL the answers and I have never thought that my knowledge and skills are beyond improvement. I take note of good research and endeavour to incorporate it into my practice.

    What Edzard Ernst and his disciples do though, is make a point of looking for the smallest flaw in any research that shows positive effects from chiropractic and use this to condemn the study. If the slightest adverse effect comes to light, they try to magnify this into some sort of catastrophic consequence that means that chiropractic should avoided at all costs.

    Blue Wode’s habit of quoting that research has shown up to 50% of patients suffering adverse effects is a case in point. THese so-called adverse effects largely equate to mild, transient soreness in an area that was, by definition, sore already because it’s what took the patient to the chiropractor in the first place. It’s a bit like going to the gym and feeling the post-exercise ache afterwards. If you took that as a serious adverse effect, nobody would take any exercise. If you see a little blood when spit out your toothpaste, have you suffered an adverse effect from brushing your teeth? Do you decide that brushing your teeth is now a dangerous activity, to be avoided at all costs?

    The detractors from chiropractic show themselves up by refusing to acknowledge that there are any benefits at all. In the face of the evidence, however they like to manipulate it, that’s bias.

  • David wrote: “…the BCA took Simon Singh to task because he made an untrue, defamatory statement about the actions of the BCA which he then refused to retract.”

    Are you able to give a valid reason as to why the BCA didn’t take up the Guardian’s offer of a published response to Simon Singh’s statements? The BCA could have easily set the record straight in a very public manner. Even if the BCA’s evidence turned out to be useless (as now seems to be the case), then surely that would be a step forward for healthcare since the ineffective interventions could then be discarded in favour of interventions (not necessarily administered by chiropractors) that had been proven to work. Or could the reason for the BCA’s apparent reluctance to reveal their evidence in a national newspaper be because the certainty of having a wide audience see how pathetically weak their evidence was would most likely have resulted in a detrimental effect on chiropractors’ ability to earn a good living? After all, let’s not forget that most chiropractors in the UK work in private practice.

    David wrote [re the British Chiropractic Association managing to have the Daily Telegraph remove an article entitled ‘Chiropractors are a waste time’ from its website in November 2007]: “Correct. And the reason that the article was removed was because the research that had been reported on had nothing to do with chiropractic. It was the journalist who took it upon themselves to suggest that chiropractors were involved in the study. In fact, what the study showed was that a group of physiotherapists in Australia had failed to be effective in treating a group of back pain patients by using their version of manipulation. There were no chiropractors involved and the techniques used were not chiropractic techniques. Therefore, the article was removed.”

    Not convincing. As spinal manipulation is the hallmark intervention of chiropractors, the study was highly relevant to chiropractors, even if it did involve physiotherapists only. If the study had shown a positive effect for the physiotherapists’ version of manipulation, and the title of the article had been ‘Chiropractors *aren’t* a waste of time’, would the British Chiropractic Association (and the GCC) still have complained? I think not. By the way, an accompanying editorial to the study noted this:

    • Systematic reviews had concluded that NSAIDS and spinal manipulation were more effective than placebos. However, the patients in the reviewed studies did not have optimum first-line care [unlike the patients in the study in question], and the apparent benefit was not large.
    • Advice to remain active and prescription of paracetamol will be sufficient for most patients with acute low back pain. [Koes BW. Evidence-based management of acute low back pain. Lancet 370:1595-1596, 2007]
    http://www.ncahf.org/digest07/07-47.html

    It’s also interesting to note that the discussion section of the study references a systematic review of spinal manipulation that concluded that “there is no evidence that high-velocity spinal manipulation is more effective than low-velocity spinal mobilisation, *or that the profession of the manipulator affects the effectiveness of treatment*”.
    http://www.acatoday.org/pdf/Lancet_Acute_Back_Pain_Nov.07.pdf

    David wrote: “Let’s be clear, the risk of serious adverse effects from chiropractic are miniscule. They are measured in terms of cases per MILLIONS of treatments….To suggest that chiropractors should, by law, make such a ridiculous statement as that proposed by Singh and Ernst, is just plain daft.”

    So, are you saying that despite the fact that the risk/benefit profile for spinal manipulation is largely negative, you, and other chiropractors, are quite happy to take patients’ money for an intervention for which there are equally effective, cheaper, safer, and more convenient conventional options available *and not tell them about that*? Are you aware that section B2.7 of your Code of Practice requires that chiropractors “must offer enough information to patients for them to take the decision to consent or not. If the patient is not offered as much information as they reasonably need to make their decision, and in a form they can understand, their consent may not be valid”? A related footnote explains that this would include “information on the benefits and risks of the proposed method of assessment or care and any alternative methods”.

    David wrote: “As you know, the opinion that Singh and Ernst offered on chiropractic in their book was typically negative and alarmist. On the basis of the information available to them, they could just as easily come to the conclusion that: ‘Chiropractic is a tried and tested treatment for which there is good evidence, especially in the management of neck pain, back pain and headaches. It’s effectiveness compares favourably with other treatments and, although concerns have been raised about the safety of manipulation of the neck, the risks of serious side effects have been shown to be somewhere in the region of 1 in 2,000,000’.”

    But that would be dishonest. Firstly, good evidence for effectiveness is not evidence for good effectiveness. I have conceded in the past that there is some evidence for spinal manipulation (which can be provided by other therapists who are far more evidence-based) as a short-lived pain relief treatment in a sub-group of low back pain sufferers, but it is no more effective than conventional treatments. Secondly, the frequency of serious side effects is currently not known. Indeed, this study regarding adverse effects of chiropractic http://www.ncbi.nlm.nih.gov/pubmed/19444054 concludes “there is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue”. As we know that complications related to chiropractic treatment are currently being under-reported, in the interests of patient safety, until the data are in, shouldn’t chiropractors be erring on the side of caution and abandoning cervical manipulations as an intervention when there are equally effective, cheaper, more convenient, and safer options available? On the subject of risk, I would also add that chiropractic patients are exposed to other types of harms, including:

    1. Decreased use of immunisation due to misinformation given to parents. It’s worth noting that only one out of 16 UK chiropractors who responded to this survey advised in favour of the MMR vaccination:
    http://www.dcscience.net/schmidt-ernst-vaccine-2003.pdf
    2. Psychologic harm related to unnecessary treatment
    3. Psychologic harm caused by exposure to false chiropractic beliefs about “subluxations”
    4. Financial harm due to unnecessary treatment

    David wrote “The problem with the BEAM trial is that you can’t bear the fact that it produced positive results for the style of practice employed by the vast majority of chiropractors in the UK. So, you have tried to dismiss the results by suggesting that it’s touch, rather than manipulation that might have been effective! Then, just in case people spot how ridiculous that argument is, you have tried to muddy the waters by suggesting that it might not be the chiropractors who produced the benefit, but other manipulating practitioners.”

    Please note that the BEAM trial’s effects were:

    1. Not clinically significant
    [Tveito TH, Eriksen HR. United Kingdom back pain exercise and
    manipulation (UK BEAM) trial. Is manipulation the most cost
    effective addition to ‘‘best care’’? BMJ 2005; 330: 674.]
    2. Did not include 23–26% of the study population
    [Tillett R. United Kingdom back pain exercise and manipulation
    (UK BEAM) trial. What happened to participants who were not
    included in the analysis? BMJ 2005; 330: 674.]
    3. Had a design that couldn’t control for placebo and other non-specific effects.
    [Ernst E. United Kingdom back pain exercise and manipulation
    (UK BEAM) trial. Touch may have had non-specific effect, among
    other things. BMJ 2005; 330: 673–4.]

    Further, it is apparent that chiropractors do not use spinal manipulation judiciously. For example, take the Wilson survey of 1,418 active and semi-active UK chiropractors [Wilson FJH, A survey of chiropractors in the United Kingdom, European Journal of Chiropractic, 2003:50:185-198], which appears to go some way towards supporting the findings of the 2007 survey of which you have been so critical. It had a response rate of 58% (816), and its participants included members of the British Chiropractic Association (BCA) and Scottish Chiropractic Association (SCA), educated at accredited colleges, and members of the British Association for Applied Chiropractic (BAAC) and McTimoney Chiropractic Association (MCA), educated at unaccredited colleges but grandparented to practise in the UK. A strong majority considered organic or visceral conditions (69%) and the management of children (98%) to be within the scope of chiropractic practice. It’s also worth noting that 36% agreed that “chiropractors should be allowed to prescribe medication on a restricted basis (e.g. mild analgesics, NSAIDS and muscle relaxants).”

    If the above is not correct, then why don’t Kenneth Vall DC, Principal of the Anglo European College of Chiropractic (AECC), and David Byfield DC, Head of the Welsh Institute of Chiropractic (WIOC), issue a joint public statement confirming that their colleges do not train students in the vitalist/organic model of chiropractic, and that they do not believe that the chiropractic ‘subluxation’ is a real condition with known medical consequences?

    Is there anything to prevent them from making such a declaration?

  • @ Blue Wode

    Blue Wode wrote: “…why don’t Kenneth Vall DC, Principal of the Anglo European College of Chiropractic (AECC), and David Byfield DC, Head of the Welsh Institute of Chiropractic (WIOC), issue a joint public statement confirming that their colleges do not train students in the vitalist/organic model of chiropractic…”

    I can’t think of any reason why they should issue such a statement. Im my experience of the AECC over the last twenty five years the “subluxation” model has not been a feature. As far as WIOC are concerned, I don’t believe that the “subluxation” model has been part of their program at all, ever since it’s inception. Why would the college principals produce a statement disclaiming their adherence to a concept that only you believe they hold?

    If you can find references to methods, models or beliefs in their prospectuses then feel free to ask the relevant people to explain them.

    Let’s not forget, if chiropractors are not sticking to the rules, there is a State registered body that is positioned to deal with them. It is the job of the General Chiropractic Council to police chiropractic, not you.

    As for the rest of your posting, you’re just going round the same circle of inflating perceived risks, denegrating good research and citing irrelevant references in an effort to give some weight to your prejudice against chiropractic.

    You haven’t brought anything new to the debate so I’m bowing out of this now, before I witness you disappearing up your own fundamental orifice.

  • David wrote: “Why would the college principals produce a statement disclaiming their adherence to a concept that only you believe they hold?”

    Because, assuming they have nothing to hide, it would help to give chiropractic the credibility it so desperately needs.

    David wrote: “Let’s not forget, if chiropractors are not sticking to the rules, there is a State registered body that is positioned to deal with them. It is the job of the General Chiropractic Council to police chiropractic, not you.”

    Being more reactive than pro-active, the GCC’s effectiveness as a regulator is very limited. It has also, since inception, given the impression that it is not impartial.

    As for the rest of your posting, I can only conclude that you are unable to produce any robust scientific evidence in defence of ‘chiropractic’.

  • You go David. These two are so full on bias they cant see past the end of their noses. Study after study has shown the effecacy of the CHIROPRACTIC adjustment when given by a CHIROPRACTOR. Studies have also shown that patients are dissatisfied with ‘adjustments’ given by GP’s and PT’s AND that said GP/PT’s, more often than not, quit manipulating because they dont achieve the desired result.

    If you want to talk about danger and adverse affects, I notice ‘they’ didnt mention the 200K people A YEAR who DIE from the ‘safe and less expensive alternative of aspirin. Informed consent, what a joke. Letters go out to pregnant women in the UK every day to get a flu vaccine. When they have asked they have not been allowed to read the package insert. I wonder why? could it be due to the package insert stating that the product HAS NOT BEEN TESTED ON PREGNANT WOMEN and IS NOT RECOMMENDED FOR USE FOR PREGNANT WOMEN? And yet when asked, these women are told it is safe. That is CLEARLY not informed consent.

    As David already mentioned, and you conveniently chose to ignore, serious adverse affects occur 1 in every 2 MILLION adjustments. That is just about the safest thing you can do.

    At this point, I am with David, you are spouting nonsense, you have (apparently) no personal experience with chiropractic and are willing to throw out the baby wit the bathwater. Chiropractic is a dynamnic entity that responds and adjusts (pardon the pun)to new technology and new information. Some chiropractors dont, some are just not good doctors, but that does not make the entire profession invalid.

    I’m outta here…

  • Bridgit said: “Study after study has shown the effecacy of the CHIROPRACTIC adjustment when given by a CHIROPRACTOR. Studies have also shown that patients are dissatisfied with ‘adjustments’ given by GP’s and PT’s AND that said GP/PT’s, more often than not, quit manipulating because they dont achieve the desired result.”

    Care to give any links to these studies?

    And the data that show 200,000 a year are killed by aspirin? Not that is relevant to the argument, of course.

  • “Not convincing. As spinal manipulation is the hallmark intervention of chiropractors, the study was highly relevant to chiropractors, even if it did involve physiotherapists only.”

    I think this statements shows blue wodes ignorance.

  • Fedup wrote that this statement showed my ignorance: “Not convincing. As spinal manipulation is the hallmark intervention of chiropractors, the study was highly relevant to chiropractors, even if it did involve physiotherapists only.”

    Fedup, I’d welcome some further comment from you. Are you aware that the President of the British Chiropractic Association, Richard Brown, claims in the current issue of The Backcare Journal that spinal manipulation is the “hallmark of chiropractic treatment for back pain”? Furthermore, he seems to make those comments in an eager attempt to highlight the (controversial) new NICE guidelines for low back pain which recommend spinal manipulation – administered by physiotherapists and osteopaths, as well as chiropractors. See pp36-37 here:
    http://content.yudu.com/Library/A1ks7r/BackcareWinter200910/resources/index.htm?referrerUrl=http%3A%2F%2Fwww.yudu.com%2Fitem%2Fdetails%2F117419%2FBackcare-Winter-2009-10

  • This is the basis for manipulation when you train as a physio.

    “Generally, students should be ready to progress onto manipulation by the third year of their
    undergraduate programme, when they should also have undertaken some structured clinical
    experience.”

    Please remember the physio course is 3 years long so they only progress to manipulation in their last year.

    “The manipulations taught to students is at the discretion of the university subject leader. The general
    consensus was for at least two; lumbar spine rotation and thoracic posteroanterior. There was no
    further consensus as to the particular type of manipulation being either localised or generalised, and
    this again would be at the discretion of the subject leader. At this stage there was general consensus
    that cervical manipulation should be developed at post graduate level, but again inclusion/exclusion
    of manipulation for any other area is at the discretion of the subject leader.”

    I think you will find this is very different from the level of manipulative training chiropractors get. Not one or two adjustments at the tutours discretion.

    Using a physio based manipulation study and comparing it to chiropractic is akin to giving doggy choclates to kids and saying they were from Thorntons.

    Do you know any physios? I know several. One (my brother) had a lecture titled “Manipulation- Don’t do it.” Though you could do a couple of short courses post grad to learn manipulation.

    Manipulation of all sorts works. But there is manipulation and there is manipulation. I’m not saying all physios aren’t as skilled in manipulation as chiros, I’m saying the average chiro will be better trained in manipulation than the average physio. I also feel manipulation is a dustbin description. Chiros can offer a range of different types of manipulation and the differences are important to the outcomes.

  • Fedup, isn’t the real difference between physiotherapists and chiropractors that physiotherapists know when *not* to manipulate? In other words, they seem to be far more judicious when it comes to using spinal manipulation as an intervention, and much less mired in quackery than chiropractors.

    I’d be interested to know how you think it’s possible for the public to be confident that the spinal manipulations they receive from chiropractors will be appropriate and evidence-based? That is, how can they be sure that they won’t be ensnared by chiropractic’s ‘bait and switch’? It’s a huge problem that chiropractors seem very reluctant to face:
    http://www.dcscience.net/?p=1516

    Basically, what are chiropractors – evidence-based manual therapists or cultists? As chiropractic historian Joseph C. Keating said, chiropractors can’t have it both ways, their theories can’t be both dogmatically held vitalistic constructs and be scientific at the same time.

  • I don’t agree. The real difference is that manipulation is not their primary care model. They use it occasionally, like dry needleing and interferential.
    As for “I’d be interested to know how you think it’s possible for the public to be confident that the spinal manipulations they receive from chiropractors will be appropriate and evidence-based?”

    I have talked about this on other blogs and I use a piece from Richard Dawkins God delusion where he mentions 5 groups of people.
    Group 1 beleive in god and no amout of evidence will change their minds. Group 2 beleive in God but with evidence they would change their minds. 3 are not sure either way. 4 Don’t beleive in god but with evidence they would beleive and group 5 would not beleive in God no matter what the evidence.

    A lot of religous types are in group 1 but most aethiest are in group 4, infact there is probably nobody in group 5. Anyway I got to thinking, as I’m in group 4, what would make me beleive. The only thing would be my own personal experience of god, not a RCT or scientific evidence, but something I had experienced and felt. Now I know you are thinking def a cultist but what I am trying to explain is that every member of the public that visits a chiropractor experiences a change. They feel something has altered, they feel things improve(pain, range of movement)thats why no amout of gold standard rct will change somebodies perception if chiropractic has “worked for them”

    Yes there are factors in the chiro world that use “bait and switch” and this is a problem but you can’t colour everybody with the same pencil. I have spoken to 2 PHD research scientist who come for treatment and they are of the strong opinion that a true gold standard double blind RCT is just not possible for chiropractic and anything even close would cost over a million quid. There are less than 2500 chiros in this country and most, like me, just keep our heads down and try and help people which is what we have been doing for years. I know you want evidence but the only evidence I require is from the people that come to me for treatment and the only evidence they require is that they feel better.

  • fedup said: “a true gold standard double blind RCT is just not possible for chiropractic and anything even close would cost over a million quid. There are less than 2500 chiros in this country and most, like me, just keep our heads down and try and help people which is what we have been doing for years.”

    So that’s a one-off cost of £400 a head? What’s that? 1% or 2% of a chiro’s annual income? Not exactly a high price to pay for something that might just give them a scientific – and moral – basis for how they earn their living, is it?

  • lol joe. You taking the moral high ground now? What is it that you do for a living?

  • @fedup

    Why has what I do for a living got anything to do with whether there is any good evidence for chiro and how chiros might fund that research – assuming they want to, of course? Perhaps you could answer that: are chiros actually interested in finding out if there is a scientific basis for chiro?

  • I see Zeno has written about this very subject on his About page.

  • “Not exactly a high price to pay for something that might just give them a scientific – and moral – basis for how they earn their living, is

    moral basis and how they earn their living!!!!!

  • So joe you question the moral aspects of a profession then hide in a corner when a simple question is asked about how you might benefit society. Again joe you are showing nothing but ignorance. What do you actually know about chiropractic that you haven’t read on somebody else’s blog? If you think for 1 second chiropractors feel the need to prove themselves to you, so you have the scientific evidence that would make you happy, then you are very much mistaken.
    To be honest I do not feel the need to prove myself, scientifically or otherwise to anybody but the person that has come to see me for treatment. Over 90% come as new patients on word of mouth referal. I don’t advertise, call myself Doctor or see kids under the age of 10. I’m not speaking for the whole profession but I couldn’t give a flying you know what for scientific evidence that would keep bloggers and science writers happy.

  • Calm down, fed up. Your first paragraph is pure ad hominem. What somebody does for a living or how they may or may not benefit society has no bearing on whether chiropractic is scientifically supportable.

    You say you “couldn’t give a flying you know what for scientific evidence”. That admission would seem to confirm Joe’s point. The big question about chiropractic is whether it is actually more effective than doing nothing or more effective than other treatments that are cheaper or free at the point of purchase. We can’t know whether they are until they have been scientifically tested. In other words, you could be charging people for an unnecessary treatment. That is a moral question. Get the scientific support and you can claim the moral high ground. Until then, you’re just a quack.

  • Oh! That touched a raw nerve, didn’t it?

    Who’s hiding? You methinks, by failing to address the issue here and blatantly trying to divert attention elsewhere. You certainly didn’t fool skepticat!

    You raised the question of the (alleged) high cost of a trial of chiro. I provided one possible solution to that. You, however, do not appear to think much of it.

    Now, instead of bothering to tell us why chiros should not spend a few percent of their income on conducting a trial to gain the respectability many (excluding you, it seems) seem to crave, you tried to change the subject to what I do for a living.

    Maybe you could tell me why you think that makes any difference to how a trial could be funded?

    And just how is my questioning the morality of charging people for something for which there is no robust evidence ‘showing nothing but ignorance’?

    It gets even better. After having expounded on the costs of a trial, you then try to distance yourself from it all by claiming you’re not really interested in scientific evidence after all and that you’re (presumably) more than satisfied with what you see with your own eyes.

    If you’re not interested in it, why come up with excuses not to even try? Instead, why not encourage a scientific trial, then, when it comes up with conclusions that don’t match fedup’s opinion, you can tell the scientists why they got it all wrong?

  • @ Skepticat

    You said: “The big question about chiropractic is whether it is actually more effective than doing nothing or more effective than other treatments that are cheaper or free at the point of purchase.”

    Interesting point. You are, of course, wrong in your analysis and seriously at odds with the Medical Research Council (MRC), the British Medical Journal (BMJ) and the National Institute for Health and Clinical Excellence (NICE).

    The Meade trial, sponsored by the MRC, concluded: “For patients with low back pain in whom manipulation is not contraindicated chiropractic almost certainly confers worthwhile, long term benefit in comparison with hospital outpatient management. The benefit is seen mainly in those with chronic or severe pain. Introducing chiropractic into NHS practice should be considered.” http://www.bmj.com/cgi/content/abstract/300/6737/1431

    There are inevitably those who would try to dismiss the results of this excellent trial, so before anyone steps in, here is the author’s response to criticism: “Patient satisfaction is increasingly recognised as an important outcome in trials. Whatever interpretation Ernst and Assendelft place on changes in the Oswestry score, they did not mention in their letter that significantly more of those patients in our trial who were treated by chiropractic expressed satisfaction with their outcome at three years than those treated in hospital.”

    The UK BEAM trial concluded: “Spinal manipulation is a cost effective addition to “best care” for back pain in general practice. Manipulation alone probably gives better value for money than manipulation followed by exercise.” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC535455/

    NICE, in their most recent guidelines for the management of low back pain, advise considering “offering a course of manual therapy, including spinal manipulation, comprising up to a maximum of nine sessions over a period of up to 12 weeks.” http://www.nice.org.uk/nicemedia/pdf/CG88QuickRefGuide.pdf

    They then describe the practitioners who might administer this manipulation: “Manipulation can be performed by chiropractors or osteopaths, and by doctors or physiotherapists who have undergone specialist post-graduate training in manipulation.” The important part of that last statement being that doctors or physiotherapists who intend to offer this type of treatment must have undergone the requisite post-graduate training.

    All in all, the consensus from those who can be taken seriously is that chiropractic is a good thing, and that it should be offered on the NHS.

    So, not only effective but cost-effective as well and, if implemented as advised by the MRC and NICE, free at the point of delivery.

  • Joe you are a rather sad person. I will deal with you no more.
    good bye. on the dole I suspect.

  • Fedup wrote the following about physiotherapists: “The real difference is that manipulation is not their primary care model. They use it occasionally…”

    But that’s exactly my point. Physiotherapists use spinal manipulation judiciously, whereas chiropractors, apparently, do not. Bearing in mind that around 60-70% of UK chiropractors in a recent survey admitted that chiropractic philosophy (subluxation theory) was important to their practices, the following is lifted from a recent article by Samuel Homola, DC:

    Quote
    “When the RAND (Research and Development) organization published its review of the literature on cervical spine manipulation and mobilization in 1996, it concluded that only about 11.1% of reported indications for cervical spine manipulation were appropriate…Since about 90% of manipulation in the United States is done by chiropractors (1) who use spinal manipulation as a primary treatment for a variety of health problems, neck manipulation is more problematic among chiropractors than among physical therapists and other practitioners who use manipulation only occasionally in the treatment of selected musculoskeletal problems…Manipulation of the upper cervical spine should be reserved for carefully selected musculoskeletal problems that do not respond to such simple measures as time, massage, exercise, mobilization, longitudinal traction, or over-the-counter medication…There is evidence to indicate that cervical spine manipulation and/or mobilization may provide short-term pain relief and range of motion enhancement for persons with subacute or chronic neck pain.(1) There is no credible evidence, however, to indicate that neck manipulation is any more effective for relieving mechanical neck disorders than a number of other physical treatment modalities,(9) and it is clear that adverse reactions are more likely to occur following manipulation than mobilization.(10)…All things considered, manual rotation of the cervical spine beyond its normal range of movement is rarely justified. The neck should *never* be manipulated to correct an asymptomatic “chiropractic subluxation” or an undetectable “vertebral subluxation complex” for the alleged purpose of restoring or maintaining health or to relieve symptoms not located or originating in the neck. There is no evidence that such subluxations exist. When a painful, actual subluxation (partial dislocation) occurs, manipulation might occasionally be helpful but is most often contraindicated.(13) …A physical therapist trained in the use of both manipulation and mobilization for musculoskeletal problems would be less likely to use manipulation inappropriately than a chiropractor who routinely manipulates the spine for “the preservation and restoration of health.”(15)…According to the Association of Chiropractic Colleges (ACC), “Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.”15 Chiropractors who are guided by this vague paradigm (more of a belief than a theory) often manipulate the full spine of *every* patient for “subluxation correction”. Few chiropractors specialize in the care of back pain and other musculoskeletal problems, and only a few have renounced the chiropractic vertebral subluxation theory…Whatever the incidence of stroke per number of neck manipulations might be, this risk is greater *per patient* among chiropractic patients who may be manipulated many times for “health reasons” and who may be manipulated regularly for “maintenance care.” Chiropractors who renounce vertebral subluxation dogma and specialize in the care of back pain will use manipulation more appropriately. Unfortunately, there is no official or legal definition limiting chiropractors to treatment of musculoskeletal problems, making it difficult to find a properly limited chiropractor.(17)
    http://www.sciencebasedmedicine.org/?p=1037

    It hardly paints a reassuring picture, does it? And let’s also not forget that a systematic review concluded that chiropractic tests for detecting lesions in the lumbo-pelvic spine were hypothetical, and therefore unreliable:
    http://www.ncbi.nlm.nih.gov/pubmed/10820299

    As for my saying “I’d be interested to know how you think it’s possible for the public to be confident that the spinal manipulations they receive from chiropractors will be appropriate and evidence-based?”, and your reply “…I use a piece from Richard Dawkins God delusion where he mentions 5 groups of people. Group 1 beleive in god and no amout of evidence will change their minds. Group 2 beleive in God but with evidence they would change their minds. 3 are not sure either way. 4 Don’t beleive in god but with evidence they would beleive and group 5 would not beleive in God no matter what the evidence…A lot of religous types are in group 1 but most aethiest are in group 4, infact there is probably nobody in group 5. Anyway I got to thinking, as I’m in group 4, what would make me beleive. The only thing would be my own personal experience of god, not a RCT or scientific evidence, but something I had experienced and felt. Now I know you are thinking def a cultist…”

    Well, you certainly don’t seem to be a critical thinker with a good grounding in science, IMO. Also, you are incorrect about the Dawkins Theist-Atheist Scale. Most atheists are in group 6, including Dawkins himself. Here’s the scale, lifted from p.50 of The God Delusion:

    Quote

    1.00: Strong theist. 100 percent possibility of God. In the words of C.G. Jung, ‘I do not believe, I know.’

    2.00: Very high probability but short of 100 per cent. De facto theist. ‘I cannot know for certain, but I strongly believe in God and live my life on the assumption that he is there

    3.00: Higher than 50 per cent but not very high. Technically agnostic but leaning towards theism. ‘I am very uncertain, but I am inclined to believe in God.’

    4.00: Exactly 50 per cent. Completely impartial agnostic. ‘God’s existence and non-existence are exactly equiprobable.’

    5.00: Lower than 50 per cent but not very low. Technically agnostic but leaning towards atheism. ‘I don’t know whether God exists but I’m inclined to be sceptical.’

    6.00: Very low probability, but short of zero. De facto atheist. ‘I cannot know for certain but I think God is very improbable, and I live my life on the assumption that he is not there.’

    7:00: Strong atheist. ‘I know there is no God, with the same conviction as Jung ‘knows’ there is one.’

    (http://forum.richarddawkins.net/viewtopic.php?f=3&t=742)

    Fedup wrote: “Yes there are factors in the chiro world that use “bait and switch” and this is a problem but you can’t colour everybody with the same pencil.”

    True, but you can colour a significant number (at least a third) of chiropractors in the UK with the same pencil – and that’s the ones who were *willing to admit* to practicing vitalistic quackery.

    Fedup wrote; “I have spoken to 2 PHD research scientist who come for treatment and they are of the strong opinion…”

    Irrelevant appeal to authority.

    Fedup wrote: “There are less than 2500 chiros in this country and most, like me, just keep our heads down and try and help people which is what we have been doing for years.”

    I suspect that most of you are keeping your heads down hoping that the increasing scrutiny of your trade will go away, otherwise your lucrative (and some might say fraudulent) income streams are in danger of suffering irreparable damage.

    Fedup wrote: “I know you want evidence but the only evidence I require is from the people that come to me for treatment and the only evidence they require is that they feel better.”

    In other words, just the sort of evidence that psychics, astrologers, faith healers, and homeopaths, etc., rely on.

    Fed up said to Joe: “If you think for 1 second chiropractors feel the need to prove themselves to you, so you have the scientific evidence that would make you happy, then you are very much mistaken. To be honest I do not feel the need to prove myself, scientifically or otherwise to anybody but the person that has come to see me for treatment…I’m not speaking for the whole profession but I couldn’t give a flying you know what for scientific evidence that would keep bloggers and science writers happy.”

    Careful now. It’s worth remembering that there’s very little that the Advertising Standards Authority will accept as evidence to substantiate chiropractic practices.

    David said to Skepticat: “You are, of course, wrong in your analysis and seriously at odds with the Medical Research Council (MRC), the British Medical Journal (BMJ) and the National Institute for Health and Clinical Excellence (NICE).”

    David, surely you are aware that the results of the Meade trial, sponsored by the MRC, were clinically insignificant? You can find a recent analysis here: http://www.dcscience.net/?p=1718

    Similarly, the BEAM trial’s effects were:
    1. Not clinically significant
    [Tveito TH, Eriksen HR. United Kingdom back pain exercise and
    manipulation (UK BEAM) trial. Is manipulation the most cost
    effective addition to ‘‘best care’’? BMJ 2005; 330: 674.]
    2. Did not include 23–26% of the study population
    [Tillett R. United Kingdom back pain exercise and manipulation
    (UK BEAM) trial. What happened to participants who were not
    included in the analysis? BMJ 2005; 330: 674.]
    3. Had a design that couldn’t control for placebo and other non-specific effects.
    [Ernst E. United Kingdom back pain exercise and manipulation
    (UK BEAM) trial. Touch may have had non-specific effect, among
    other things. BMJ 2005; 330: 673–4.]

    As for NICE’s recent guidelines for the management of low back pain, presumably you are aware that (1) the manipulative therapies were over-represented on the Guideline Development Panel, (2) they didn’t take into account the ‘bait and switch’ of pseudoscientific medicine like chiropractic http://www.dcscience.net/?p=1516 , and (3) the risks of spinal manipulative therapy, as administered by chiropractors, were underestimated. Indeed, here’s what Edzard Ernst had to say about the latter in his critique of the guidelines:

    Quote
    “Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.”
    [Ref: Ernst, E. Spinal manipulation for the early management of persistent non-specific low back pain - a critique of the recent NICE guidelines, Int J Clin Pract, 18th August 2009. Reprints available from author.]

    So, all in all, it would seem that not only is chiropractic pretty much a (potentially dangerous) waste of time and money, it is also so heavily riddled with deception that it should never be offered on the NHS.

    BTW, I’d still like to know what’s preventing Kenneth Vall DC, Principal of the Anglo European College of Chiropractic (AECC), and David Byfield DC, Head of the Welsh Institute of Chiropractic (WIOC), issuing a joint public statement confirming that their colleges do not train students in the vitalist/organic model of chiropractic, and that they do not believe that the chiropractic ‘subluxation’ is a real condition with known medical consequences.

  • @Blue Wode

    Of course David is well aware of the paucity of the evidence in the MEADE and BEAM trials and the severe problems with the NICE guidance! Chiros just don’t have anything better!

  • @ Joe

    “Of course David is well aware of the paucity of the evidence in the MEADE and BEAM trials and the severe problems with the NICE guidance! Chiros just don’t have anything better!”

    But Joe, it doesn’t need to get any better than that. Ringing endorsements from the MRC and NICE are just the type of evidence that sensible, serious people rely on to form their opinions.

    Unfortunately, you appear to belong to the group of people for whom no amount of evidence will be enough. That’s not scepticism, that’s bigotry.

  • @ Blue Wode

    “BTW, I’d still like to know what’s preventing Kenneth Vall DC, Principal of the Anglo European College of Chiropractic (AECC), and David Byfield DC, Head of the Welsh Institute of Chiropractic (WIOC), issuing a joint public statement confirming that their colleges do not train students in the vitalist/organic model of chiropractic, and that they do not believe that the chiropractic ‘subluxation’ is a real condition with known medical consequences.”

    What I’d like to know is why you think that you have the authority to make such a demand. Who are you? What are your credentials? Why should the heads of two internationally respected academic institutions respond to the demands of an anonymous ranter on someone else’s blog?

    I’m not suggesting you don’t have the authority, what I’m asking is, what IS your authority. Come on, reveal yourself. If you feel that you are so right, then stand up and be counted.

  • @David

    Ringing endorsement??? Are you reading the same document as Joe and I or have you not bothered to read any of the criticism of the guidance? I can point you in the direction of that criticism if you are unaware of it.

    Now, if the NICE guidance had said something like: “robust clinical trials have shown chiro as by far the most proven effective way of treating back pain and we heartily recommend its use”, then I might be inclined to take a bit more notice. As it is, we both know it falls somewhat short of that. In fact chiro hardly gets a look in. Barely a passing mention.

    Very odd, in fact, considering the committee was packed by AltMed supporters, that they couldn’t find it in themselves to be a bit clearer about the supposed benefits of chiro. Perhaps they knew they were scraping the bottom of the barrel as it was!

    However, if you want to continue the discussion about the efficacy of chiropractic, please address the concerns about the NICE guidance.

    You try to tell Joe that for him, ‘no amount of evidence will be enough’. How you know what is in his mind is certainly not clear, but perhaps you can tell me what would make you change your mind about chiro. Or are you religiously wedded to it, blind to all criticism and evidence?

    And please refrain from calling someone a bigot. It’s not nice and it’s not clever.

  • @ David

    It is completely irrelevant who I am, or what my credentials are.

    Until there is formal, public, confirmation that it is not the case, one can only conclude from your response is that it is entirely possible that the Anglo European College of Chiropractic (AECC) and the Welsh Institute of Chiropractic (WIOC) not only train their students in the vitalist/organic model of chiropractic, but also lead them to believe that the chiropractic ‘subluxation’ is a real condition with known medical consequences.

    Now would you please address the concerns posted here about the NICE guidelines. (Drive-by readers can click on “Older Entries”, bottom right, to learn what these concerns are.)

  • @ Blue Wode

    “It is completely irrelevant who I am, or what my credentials are.

    Until there is formal, public, confirmation that it is not the case, one can only conclude from your response is that it is entirely possible that the Anglo European College of Chiropractic (AECC) and the Welsh Institute of Chiropractic (WIOC) not only train their students in the vitalist/organic model of chiropractic, but also lead them to believe that the chiropractic ‘subluxation’ is a real condition with known medical consequences.”

    Not good enough I’m afraid. Following your argument, one can only conclude that it’s entirely possible you are a raving loony who has an axe to grind and/or a vested interest in causing mischief for the chiropractic profession.

    So, who is it that’s demanding this statement from AECC and WIOC? Is it the state regulator for chiropractic, the General Chiropractic Council? No, it’s not.

    Is it the CHRE (Council for Healthcare Regulatory Excellence), the umbrella organisation that oversees healthcare regulators in the UK? No, it’s not.

    So who is it? Well, it’s someone calling themselves “Blue Wode”. What are his/her qualifications? We don’t know. What are his/her intersets? We don’t know. What gives them the authority to make such demands? Heaven only knows.

    However, “Blue Wode”seems to think that they are important enough that everyone ought to be jumping to satisfy his/her demands.

    So Blue Wode, if you are so insistent that you should be answered, you will have to come up with some reason why you should be listened to. If you want to be taken seriously, reveal yourself and your credentials. Until you do, you have no remit or authority.

  • @Zeno

    Zeno said: “However, if you want to continue the discussion about the efficacy of chiropractic, please address the concerns about the NICE guidance.”

    It’s not for me to defend NICE’s guidelines. I’m just a lowly chiropractor who reads the research and incorporates the evidence into my everyday practice.

    However, it is quite nice that NICE have endorsed my mode of practice for the management of low back pain.

    Zeno said: “And please refrain from calling someone a bigot”

    I didn’t call Joe a bigot. What I said was that s/he *appears* to belong to the group of people for whom no amount of evidence will be enough”. A person who does belong to that group could reasonably be called a bigot.

    Bigot –noun
    “A person who is utterly intolerant of any differing creed, belief, or opinion.”

  • @ David

    Given that the questions being asked by the skeptical posters here are clearly in the public interest, I’m curious to know why you’re so reluctant to answer them. Could it be because you can’t?

  • @ Blue Wode

    Still trying to side-step the issue, I see.

  • @ David

    No, I have already addressed the issue above. Who I am, and what my credentials are, are totally irrelevant to this discussion.

  • @ Blue Wode

    Still not good enough!

  • You’re the one side stepping the issue, David. BW isn’t “demanding” anything. He’s simply asking why the colleges don’t publicly state a couple of things. It’s a fair question that you are evidently unable to answer so you call the question a “demand” then try to divert attention on to whether BW has credentials to make such a demand, when he didn’t make one in the first place.

    Must try harder.

  • “Given that the questions being asked by the skeptical posters here are clearly in the public interest,”

    Now thats funny. The questions here are being asked by several intellegent people, who probably have nothing better to do, for some reason known only to them, have a problem with anything they don’t beleive in because ” the evidence is not up to standard”
    Now these people may not be qualifed to examine scientific evidence, they almost certainly know nothing about chiropractic yet they think for some strange reason they are acting on behalf of the great british public!!!

    I have over 4000 members of the british public that would tell you they have, and still do, benefit from chiropractic care. My colleague down stairs has the same. David will probably have as many or even more. I’m sure they would all be really pleased to know you are asking these questions on their behalf even though you don’t have a clue as to what you are actually talking about and thousands and thousands of the british public will tell you you are wrong.

  • Fedup, the appeal to popularity argument (argumentum ad populum), does not make something so. It remains apparent that chiropractic is increasingly struggling to find good evidence for its interventions beyond non-specific (placebo) effects.

    I suggest that you have a read through the late Barry Beyerstein’s classic essay, ‘Social and Judgmental Biases That Seem to Make Inert Treatments Work’. It is a thorough analysis of alternative medicine and common errors of reasoning:
    http://www.sram.org/0302/bias.html

  • BW
    “The founding editor of this publication, Wallace Simpson, has long opposed natural medicine in any form, without actually evaluating the evidence involved. In fact, he has said, “When we began the journal, we did so simply because no one else was doing it. By definition, we have to start with the premise that alternative medicine claims are all unproven or false” (CSICOP 1999). To start with the assumption that all claims are false is not scientific and in fact reveals incredible bias.”

    “In conclusion, SRAM should simply be ignored as an ongoing diatribe against all of natural medicine by a group that, by their own admission, starts with a set conclusion and basically ignores the full breadth of evidence available on the subject.”

  • Fedup, let’s get real. Of course a publication entitled ‘The *Scientific* Review of Alternative Medicine’ is going to evaluate the evidence. Your quoting the opinions of a naturopath really doesn’t do you any favours:
    http://www.dryarnell.com/opinions.html

  • fed up, wrote

    “The questions here are being asked by several intellegent people, who probably have nothing better to do, for some reason known only to them, have a problem with anything they don’t beleive in because ” the evidence is not up to standard”
    Now these people may not be qualifed to examine scientific evidence, they almost certainly know nothing about chiropractic yet they think for some strange reason they are acting on behalf of the great british public!!!

    fed up, you’re repeating same fallacious argument that David keeps making.

    You surely agree that anything concerning people’s health is a matter of public interest. You presumably also agree that it is important to establish the truth about therapies that are promulgated as beneficial to people’s health, whatever these are.

    But instead of welcoming questions that are aimed at eliciting the truth, you, David and any number of other altmed therapists who (‘probably having nothing better to do than’) comment on various skeptic blogs, try to get the questioners to shut up. And you do this by resorting to ad hominems about what people do for a living, what we know or don’t know already, what we are qualified to say, how we have too much time on our hands, etc. etc.

    Excuse me, but we are all affected by matters of public health and we are all entitled – and “qualified” – to ask questions about it.

    Your fallacious arguments aren’t going to change anyone’s mind about chiropractic and I respectfully suggest you do a course in critical reasoning.

  • I’m sure you’ve seen this.
    http://www.chiroandosteo.com/content/pdf/1746-1340-18-4.pdf

    “Few, if any, trials of manual therapy have
    been designed to show that an established treatment is ineffective. Many negative
    trials are too small to have been certain that an important therapeutic effect has not
    been overlooked. Thus, it is important when reading this report to remember that
    absence of evidence of effectiveness is not the same as evidence of absence of
    effectiveness.”

    “there is now little dispute amongst knowledgeable
    scientists that manipulation is of value in the management of back pain, neck pain and
    headaches that make up 90% or more of all patients who seek chiropractic care. At the
    same time, a close review of the evidence, including the recent large population
    studies in Ontario (2), have demonstrated that the incidence of serious side effects
    such as stroke following chiropractic care is extremely rare and is probably not related
    to manipulation in most patients but due to the fact that patients develop neck pain or
    headache as a result of a dissection of a vertebral artery that progresses through the
    natural history of dissection to stroke irrespective of the clinician the patient consults.”

  • @ fed up

    Yes, I have seen the report, but not read the pdf yet. FYI, Zeno has just blogged about it here:
    http://www.zenosblog.com/2010/02/the-gccs-plethora/

    “…at face value, it is a damning indictment of a vast number of claims chiropractors have been making”.

  • Just no pleasing some people.

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