The random thoughts of a sceptical activist

NHS Choices

The NHS Choices website has the tag line “Your health, your choices” and aims to inform the public:

NHS Choices is the online ‘front door’ to the NHS. It is the country’s biggest health website and gives all the information you need to make choices about your health.

They provide first-rate information about your health, illnesses, careers, etc as well as helping you find a local GP or other NHS services.

They also have some pages on alternative therapies such as homeopathy. On the page for homeopathy, they say:

Homeopathy is a type of complementary and alternative medicine (CAM). CAMs are treatments that are not based on conventional scientific theories. Other CAMS include:

  • acupuncture – where needles are placed in certain parts of the body,
  • chiropractic – where physical manipulation of the spine and joints is used to try to relieve symptoms, and
  • faith healing.

It’s good to see them place chiropractic firmly along side homeopathy, acupuncture and faith healing.

Chiropractic

I wonder what the NHS has to say about chiropractic? Well, the answer today is different to what they said just a few days ago because they updated the pages on 25 March 2010.

You can read all they have to say now here, but it is interesting to compare the changes they have just made.

They have five pages: Introduction, What happens, Common Uses, Safety and regulation and Evidence. Rather than copy all of it, I have highlighted the changes below, taken from these pages:

Old Advice New Advice
Unlike conventional treatments, the use of chiropractic is not always based on scientific evidence. Unlike conventional treatments, the use and principles of chiropractic are not always based on scientific evidence.
Theory

Chiropractic was founded by in 1895 by a Canadian grocer called Daniel David Palmer, who had no conventional medical training.

Palmer argued that most human disease is caused by misalignments of the spine that apply pressure on surrounding nerves. He called these misalignments ‘subluxations’, and believed that they blocked the flow of a natural energy, or ‘life force’, through the body. Correcting these subluxations, he argued, could restore the proper flow of energy, and so restore health.

Theory

Chiropractic was founded in the US in 1895 by a Canadian grocer and magnetic healer called Daniel David Palmer, who had no conventional medical training.

Palmer argued that most human disease is caused by misalignments of the spine that apply pressure on surrounding nerves. He called these misalignments ‘subluxations’ (a term also used in conventional medicine, where it has a different meaning) and believed that they blocked the flow of a natural energy, or ‘life force’, through the body. Correcting these subluxations, he argued, could restore the proper flow of energy, and so restore health. Thus, he saw chiropractic spinal manipulation as a treatment for virtually all human conditions.

Uses

Many chiropractors only treat bone and joint conditions, such as lower back or neck pain. Some chiropractors use the treatment on a wider range of conditions, including asthma, infant colic and irritable bowel syndrome. To learn more, read Common uses

Uses

Many chiropractors only treat conditions related to the spine, such as lower back or neck pain. Some chiropractors, however, adhere to Palmer’s doctrine and use the treatment on a wider range of conditions, including asthma, infant colic, irritable bowel syndrome and many more. See Common uses for more information.

Some chiropractors use the treatment on a wide range of conditions that are unrelated to muscles, bones and joints, such as:

  • asthma
  • allergies
  • painful periods
  • infant colic
  • fibromyalgia
  • high blood pressure and
  • mental health conditions such as depression, phobias or anxiety disorders
Some chiropractors use the treatment on a wide range of conditions that are unrelated to muscles, bones and joints, such as:

  • asthma
  • allergies
  • painful periods
  • infant colic
  • fibromyalgia
  • high blood pressure
  • mental health conditions such as depression, phobias or anxiety disorders and
  • gastrointestinal disorders (of the stomach and bowel).

They may also use chiropractic as maintenance therapy (allegedly preventing disease from occurring).

When carried out by a registered chiropractor, chiropractic is safe. Serious side effects or complications resulting from treatment are rare. [This sentence about safety has been removed, but see below.]
Serious complications that have been reported include tearing of an artery wall leading to stroke, injury to the spinal column leading to paralysis, and build-up of blood between the skull and the outer layers of the brain, which can result in coma or death. These complications usually developed after chiropractic involving the neck. Serious complications that have been reported include tearing of an artery wall leading to stroke, injury to the spinal column leading to paralysis, and build-up of blood between the skull and the outer layers of the brain, which can result in coma or death. These complications usually developed after chiropractic involving the neck. Several hundred serious complications are on record.
It is important to remember that when we use a treatment and feel better, this can be because of a phenomenon called the placebo effect, and not because of the treatment itself. It is important to remember that when we use a treatment and feel better, this can be because of  phenomena such as the placebo effect, and not because of the treatment itself. You can learn more about this by watching a video explaining the placebo effect
There is inconclusive evidence on the effectiveness of chiropractic for:

  • headaches
There is inconclusive evidence on the effectiveness of chiropractic for:

  • headaches
  • neck pain

These changes are fascinating and certainly leave the public better informed about chiropractic.

No change

But it’s also interesting to see what they have not changed.

At the outset, they set the scene by emphasising that the inventor of chiropractic, Palmer:

…had no conventional medical training.

Under the heading Does it work? they say:

There is some evidence that chiropractic may be as effective as conventional treatments for treating lower back pain. Conventional treatments for lower back pain include painkillers, exercise and physiotherapy.

There is no good quality scientific evidence that chiropractic is effective in the treatment of any other condition.

There is also no scientific evidence to support the idea that most illness is caused by misalignment of the spine.

Says it all, really.

NICE

On the subject of lower back pain, the NICE guidelines are mentioned twice:

Currently, the National Institute for Health and Clinical Excellence (NICE) recommends spinal manipulation (such as chiropractic) as a treatment option for one condition: lower back pain. Read the 2009 NICE guidelines on low back pain

…but they also say:

The National Institute for Health and Clinical Excellence (NICE) provides guidelines to the NHS on use of treatments and care of patients. Currently, NICE recommends that chiropractic be considered as a treatment option for one condition:

  • lower back pain

However, there are severe and critical problems with the NICE guidelines and these have been well laid out by Professor David Colquhoun:

Evidence

On the NHS page about the evidence for chiropractic, they emphasise:

To be able to judge whether any health treatment is safe and effective, we need evidence. Evidence on a treatment is gathered by conducting fair scientific tests of the treatment.

Quite. Trials of poor methodology or ones that have been badly or incompetently conducted cannot be considered when judging chiropractic and it goes without saying that the small red fruit much beloved of AltMed supporters is not an acceptable tool.

The only condition that the NHS has considers there to be positive evidence for is lower back pain:

There is some evidence that chiropractic is an effective treatment for:

  • lower back pain

This means that scientific trials conducted to investigate the effect of chiropractic on lower back pain found that it did have a beneficial effect.

But because of disagreements over the way the trials were carried out, and over what their results mean, this evidence does not allow us to draw definite conclusions. Some scientists believe that the best fair tests show that chiropractic is not effective for lower back pain. More research is needed before firm conclusions can be drawn.

So, one the one hand, even for the one condition they say they believe there is positive evidence for, they are still equivocal and that firm conclusions about the effectiveness of chiropractic for lower back pain cannot be drawn.

Not exactly a ringing endorsement.

Further reading

It is interesting to note that the NHS’s list of which conditions fit into what evidence categories does not match the GCC’s flawed Bronfort report, although I would assume they were fully aware of it since it was published well over a month ago.

Indeed, instead of referring readers to the GCC’s $20,000 report, they used a reliable, independent source:

This information is based on The Desktop Guide to Complementary and Alternative Medicine: An Evidence-Based Approach (2006). 2nd edn. Ernst E, Pittler MH and Wider B, eds.

14 Responses to NHS Choices

  • Hmmm! Not surprising to see that the reference listed is dear, old Edzard Ernst. Hardly noted for being “a reliable, independent source”.

    Better known for being as unremittingly negative campaigner aginst chiropractic. Thankfully, NICE took a wider look than just relying on Ernst.

  • David,
    As a reliable and independent source, I am a negative campaigner against stabbing people in the eyes with red hot pokers.

    Just because you campaign against something, doesn’t mean you’re wrong or biased. You can be right.

  • @ Gib

    Sadly, the evidence shows that Prof. Ernst is biased and invariably chooses to put as negative spin on the evidence as he can find.

    Purely as a result of him being “the World’s first Professor of complementary and alternative medicine”, he gets listened to. Interestingly, the funding for his chair is under threat…….

  • David

    Haven’t we been here before?

    1. What’s your evidence that Ernst is biased?

    2. What’s your evidence that he ‘invariably chooses to put as negative spin on the evidence as he can find’?

    3. Do you think that because there is some concern over the funding of his chair, this affects the evidence – or lack of it – for any review he’s done?

  • @ Zeno

    Yes, we have been here before and while Edzard Ernst remains the main source of reference for matters pertaining to chiropractic, it’s right that he should be scrutinised.

    The evidence for suggesting that he is biased comes from the fact that he does indeed always put the most negative spin possible on the available evidence. No matter what conclusions the research points to, his description of them is always as dramatic and alarmist as he can manage.

    Interestingly, I had confirmation of this from a completely independent and unrelated medical source only last week.

    I would be very interested to know the exact reasons for the withdrawal of funding for his his chair. It seems very unclear currently which in itself raises suspiscion.

  • David said: “Edzard Ernst remains the main source of reference for matters pertaining to chiropractic”

    Really? What about Bronfort, Haas, Evans, Leininger, Triano, Theil, Bolton, Breen and the dozens of others (at chiro colleges here and in the US, Canada, etc) all publishing research into chiropractic? Or do you dismiss them?

    “it’s right that he should be scrutinised.”

    No. It is right that his reviews should be scrutinised. That’s what science is all about.

    I asked: “What’s your evidence that Ernst is biased?”

    Your reply was: “The evidence for suggesting that he is biased comes from the fact that he does indeed always put the most negative spin possible on the available evidence.”

    Can you now answer questions 2 and 3?

    “No matter what conclusions the research points to, his description of them is always as dramatic and alarmist as he can manage.”

    Can you also give your evidence for this?

  • Zeno said: “David said: “Edzard Ernst remains the main source of reference for matters pertaining to chiropractic”
    Really? What about Bronfort, Haas, Evans, Leininger, Triano, Theil, Bolton, Breen and the dozens of others (at chiro colleges here and in the US, Canada, etc) all publishing research into chiropractic? Or do you dismiss them?”

    You said it yourself in this very post post : “This information is based on The Desktop Guide to Complementary and Alternative Medicine: An Evidence-Based Approach (2006). 2nd edn. Ernst E, Pittler MH and Wider B, eds.”

    Your suggestion is that these authors (primarily Ernst) gives this information more legitimacy than the latest comprehensive review published by Bronfort in 2010. I’m not the one dismissing other authors contributing to the research base for chiropractic.

    Zeno said:” It is right that his reviews should be scrutinised. That’s what science is all about.”

    Correct. And the part of any review that most people pay attention to is the conclusion and the abstract, which are the places where Ernst invariably gives his particularly negative brand of comment.

    I am not going to air his opinions again here, I’ll let you and Blue Wode do that.

    Perhaps the better way to prove the point is for you to show us any conclusions that Ernst has come to regarding chiropractic that are not negative. It is well established that there is good evidence for chiropractic management of musculoskeletal disorders and if Edzard Ernst is unbiased towards chiropractic then surely there would be some acknowledgement of this?

    Zeno said: “Do you think that because there is some concern over the funding of his chair, this affects the evidence – or lack of it – for any review he’s done?”

    I didn’t suggest that the vulnerability of his post has affected the quality of the evidence he produces. The point I was making is that we don’t know why his funding is under review, and that we can only suppose what factors have been involved in the decisions his benefactors have come to.

  • David wrote: “Perhaps the better way to prove the point is for you to show us any conclusions that Ernst has come to regarding chiropractic that are not negative. It is well established that there is good evidence for chiropractic management of musculoskeletal disorders and if Edzard Ernst is unbiased towards chiropractic then surely there would be some acknowledgement of this?”

    I happen to have a copy of The Desktop Guide to Complementary and Alternative Medicine: An Evidence-Based Approach (2006). 2nd edn. Ernst E, Pittler MH and Wider B, eds.

    In the concluding part of the chiropractic section, which focuses on giving a risk-benefit assessment, it says:

    Quote
    “Chiropractic treatment might be helpful for low back pain, but the evidence is not convincing. In view of the lack of truly effective conventional treament for this indication, chiropractic might therefore be worth considering for such patients. For all other indications the evidence is even less compelling. Severe adverse events may be infrequent but mild transient complaints are common.”

    Seems more than fair to me. (He also cites all of the Cochrane systematic reviews related to spinal manipulation in the references.)

  • David wrote: “I didn’t suggest that the vulnerability of his post has affected the quality of the evidence he produces. The point I was making is that we don’t know why his funding is under review, and that we can only suppose what factors have been involved in the decisions his benefactors have come to”.
    I don’t think there is much mystery about the funding. Professor Ernst’s post (Laing Professor of Complementary Medicine) was funded largely by Sir Maurice Laing in 1993. Sir Maurice was head of the Laing construction company, and the first President of the Confederation of British Industry, and an enthusiast for complementary medicine. The initial grant was £1.5 million, and the University of Exeter undertook to help source a further £1.5 million for continuation of the programme when the initial funding ran out. If I recall correctly, and much to his credit, Sir Maurice did continue to support Professor Ernst in post, even though the emerging conclusions were probably not what he hoped for. The funding supports not just Professor Ernst, but also the Centre he leads, and it is the work of the researchers in the Centre which make the publications so prolific.
    However, this funding is now running out. Professor Ernst’s view, I believe, is that the University of Exeter has failed to meet its commitment to raise the continuation funding. This failure to engage may relate to the intervention of the office of the Prince of Wales, whose Foundation Professor Ernst had criticized.
    I do not know, but would hazard a guess that Professor Ernst may possibly be a tenured member of the University of Exeter staff, given the length of time he has worked there. This would mean that it is the funding for the Centre that is at risk, rather than the post itself, but I do not have definite information.
    In 2002, the Centre came under the aegis of the new Peninsula Medical School, but contracts of employment in the Medical School are either with Exeter or Plymouth Universities. The Medical School took on no responsibility for the funding continuation. Hope this helps.

  • David

    I misunderstood and thought you were referring to more than just the reference on the NHS website. My mistake.

    I don’t know why the NHS (presumably) chose not to reference, say, the GCC or the BCA, when writing their advice. You’d need to ask them.

    “Your suggestion is that these authors (primarily Ernst) gives this information more legitimacy than the latest comprehensive review published by Bronfort in 2010.”

    The normal procedure for any systematic review is to trawl for all relevant papers and assess them against predetermined quality criteria.

    Bronfort says (p7): “While critical appraisal of the included reviews and guidelines would be ideal, it is beyond the scope of the present report.”

    So it looks as if Brontfort just included whatever reviews he came across in his search, but did not evaluate any of them to gauge their quality. Whether this this was beyond the remit given to them by the GCC or whether they just chose not to, I do not know.

    It may well be that all the reviews, etc that Bronfort et al. included were of high quality, but reading Bronfort does not tell us, so, in the absence of such quality appraisal, there has to be less confidence in the conclusions of Bronfort et al.

    “Ernst invariably gives his particularly negative brand of comment.”

    We’ve been here before, but not got any further. It could well be Ernst is simply telling it like it is, but you keep claiming that he is going further than the evidence dictates yet you offer no evidence for this other than your take on it that he must be biased because you don’t agree with what he says.

    “Perhaps the better way to prove the point is for you to show us any conclusions that Ernst has come to regarding chiropractic that are not negative.”

    As you well know, all his conclusions could be negative because that’s what the evidence shows — just because they are all negative does not imply he is biased.

    “It is well established that there is good evidence for chiropractic management of musculoskeletal disorders and if Edzard Ernst is unbiased towards chiropractic then surely there would be some acknowledgement of this?”

    As far as I’m aware there is certainly not ‘good evidence’. Even the evidence for LBP is dubious. If you think otherwise, let’s see the evidence. If others choose not to acknowledge Ernst, then perhaps they are the ones who are biased?

  • WhenI first got interested in quackery, I assumed that CAM people would be grateful to Ernst for his meticulously fair assessements of evidence.

    I soon discovered that most CAM people have very little interesr in truth. Their interest seems to be in maintaining their delusions, and in maintaining their income, quite regardless of tedious facts.

  • Just thought it was interesting all the Ernst bashing going on.

    I too find it hard to believe there is not an Element of Bias in his publications.

    On conclusion of one previous study where Chiropractic was as evective as a the orthotdox option, “his spin” chiropractic is no more effective than…” could also have said “chiropractic is as effective as” same meaning different spin. Sadly cant remember the precise study, he throws out so many.

    Study design. Email a bunch of chiropractors anonymously pretend to be a patient with asthma who has been on steroids. (Would this be done to GP’s or Consultants, dont think so) Can chiropractic help and are there any risks? Concluded because osteoporosis wasnt mentioned in the reply, we potentially pose a serious risk, as he comments years later (coincedentally just after Singh lost the first Court hearing)in an online asthma journal.

    Brontfort concluded no evidence of efficacy for treating asthma and rightly so, I have never claimed it, and the GCC should have known better than to have included it in there early pamphlets even if it said the very vague “may see some improvement in”.
    But if you have asthma and get back pain of course you should see a chiropractor. I operate a DEXA scanner at our clinic and all chiropractors are well aware of the osteoporsis risk one again the study design, inference and timing of his publication by Ernst suggests Bias and lack of professional respect.

    Finally, if your co-author got dragged through the mill like Simon Singh (and I agree that libel cases should not be that expensive) I would find it quite hard to remain unbiased.

    The tedious facts are, in research trials fairness would be we should be compared with the equivolent orthodox manual therapy given for a particular complaint. Its strange the absence of the same scrutiny and critisms for physiotherapy. Physios must be “professionally restrained” (HPC pamphlet)in their advertising. Chiropractic has specifically used the term evidence based in GCC regulations. This should be applauded, but perhaps more wishy washy terminolgy like the HPC physiotherapy pamphlet would have reulted in less of a problem for us.

    Chiropractic sadly by being a “broad church” and trying to be “inclusive” to those who believe in Subluxations made itself a soft and easy target as the homeopaths are. Hopefully recent public statements by the GCC that subluxation does not cause disease, it is unsupported by evidence, and is only taught as a historical concept all the UK colleges (and it was the same 18 years ago when I studied) might suggests to some of the skeptics we arent all deluded. Chiropractic has a quiet split and could be considered as 2 distinct factions, those who very much see themselves as alternative healthcare paractitioners and those who specialise in muscoloskeletal complaints.

    I personally object to the statement I am trying to maintain a delusion this is grossly unfair to the majority of chiropractors in practice, saying that I David might be right in some cases.

  • Eugene wrote: “Chiropractic sadly by being a “broad church” and trying to be “inclusive” to those who believe in Subluxations made itself a soft and easy target as the homeopaths are. Hopefully recent public statements by the GCC that subluxation does not cause disease, it is unsupported by evidence, and is only taught as a historical concept all the UK colleges (and it was the same 18 years ago when I studied) might suggests to some of the skeptics we arent all deluded. Chiropractic has a quiet split and could be considered as 2 distinct factions, those who very much see themselves as alternative healthcare paractitioners and those who specialise in muscoloskeletal complaints.”

    But Eugene, you seem to be missing a very fundamental point:

    Quote
    “…you have a situation where the public are unable to tell who is right or wrong and therefore can have no confidence in any of the claims being made.”

    See here to learn more about the problem
    http://www.zenosblog.com/2010/05/in-memoriam/comment-page-2/#comment-5702

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