Zeno's Blog

@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.

@ 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: 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: 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.)

@ 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 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

@ 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, 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.

@ 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?

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

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

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.

@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?

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?

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’.

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.

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

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.

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?

@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?

“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!!!!!

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.

@ 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.

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.

@ 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.