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:
- Dr Carl Irwin & Associates
- Larsen Health Care Ltd
- Koren Publications (see Skeptic Barista’s blog post for details)
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
120 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.
[...] This post was mentioned on Twitter by Blue Wode, Blue Wode, mjrobbins, mjrobbins, Mike Ward and others. Mike Ward said: RT @zeno001: Zeno's Blog » Discover Chiropractic: http://is.gd/773X3 #singhbca [...]
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.