The random thoughts of a sceptical activist

The Cracklash begins

It’s not just the evidence for chiropractic that’s a bit shaky these days.

For a long time, there has been an uneasy truce between the different chiropractic factions in the UK, all believing different things and each with different rituals.

It seems that they all came together when statutory regulation was first mooted and the carrot of respectability that that offered overcame those fundamental differences — temporarily at least.

Since the GCC was set up, the trade bodies representing the different factions (‘straights’, ‘mixers’, etc) appear to have been reluctant bedfellows, and there seems to have been various fallings out and lots of jostling for position and power.

But they trundled along and put a brave face on things for the sake of the profe$$ion.

After the BCA’s misconceived attack on Simon Singh, sceptical eyes were focused on chiropractic and the claims made by its followers. After being disgusted by the claims we saw being made by a large number of chiropractors on their websites, Simon Perry and I independently poked the GCC with a somewhat sharp stick.

What a hornet’s nest we stirred up, with the GCC eventually acknowledging that chiropractic had to be based on proper evidence and not on wishful thinking.

Skeptic Barista prodded and poked the GCC in an attempt to find out just how evidenced-based they wanted to be and to find out whether they were, indeed, committed to an evidence based foundation for chiropractic. Their initial stance was:

The General Council has never considered the research evidence for the chiropractic vertebral subluxation complex.

An astonishing admission by a body charged by Parliament to regulate chiropractors and to set standards for chiropractic training.

However, gently poking further, they eventually pronounced the subluxation to be “an historical concept” and that:

There is no clinical research base to support claims that the chiropractic vertebral subluxation complex is the cause of disease or health concerns.

More on this can be found here.

Education education education

But what is being taught to the latest batches of students? The GCC asked (cached) the three training outfits:

  • how the chiropractic vertebral subluxation complex (VSC) is covered in the detailed curriculum
  • what relevant research they draw from

Each of them (the Anglo-European College of Chiropractic, the McTimoney College of Chiropractic and the Welsh Institute of Chiropractic) answered with varying degrees of enthusiasm and the GCC concluded that:

  • The chiropractic vertebral subluxation complex is taught only as an historical concept.
  • There is no clinical research base to support the belief that it is the cause of disease or health concerns

So if they are to be believed, there will be no conflict and opposing factions in the future because all new trainee chiropractors will learn that it is just an historical concept, consigned to the history books as an outdated and irrelevant concept that explains absolutely nothing and based on no evidence whatsoever; something dreamed up 120 years ago by a magnetic therapy salesman.

But we know that as recently as December 2008, the subluxation loomed large in the prospectus of the McTimoney college for their MCHiro ‘degree’:

…healing can be encouraged to take place by the detection and correction of bony subluxations (slight displacements)

Subluxations, or misalignments, in the body can occur at any time. They may be related to accidents, sporting activities, household tasks, emotional and physical stress, even a bad mattress.

When subluxations occur, a person can experience pain – of any description, of any duration, anywhere down the course of the nerve. This may lead to malfunction in either the muscles or internal organs. For example, tingling fingers can often be caused by subluxation of the neck vertebrae.

If they really have now binned the concept of the subluxation there must have been an extraordinary volte-face at the college since then! Or they have simply given it a new identity and speak of it in whispers lest an outsider hears.

No. They still talk about subluxations on their website as if they are the very foundation of chiropractic.

How Chiropractic Works

The nervous system is responsible for all body functions. The correct alignment of vertebrae in the spinal column is vital to maintain nerve pathways. Subluxations in the body can occur at any time. They may be related to accidents, sporting activities, household tasks, emotional and physical stress, even a bad mattress. Some causes are so subtle that changes can occur without the patient’s knowledge, as symptoms can take years to arise. Chiropractors believe that much ill health in adult life may be related to events such as accidents in childhood.

When subluxations occur, a person can experience pain – of any description, of any duration, anywhere down the course of the nerve. This may lead to malfunction in either the muscles or internal organs. For example, tingling fingers can often be caused by subluxation of the neck vertebrae. (Source, cached)

The lead author of the Bronfort Report, Gert Bronfort, works for Northwestern Health Sciences University — an establishment that gives degrees in chiropractic, acupuncture, TCM and massage therapy. While he did not look at the evidence for the existence of subluxations, it is against his report that chiropractic claims (and my complaints) are now being measured. Strange, then, that his establishment seems quite taken with the idea of the subluxation. Indeed, there are some 60 mentions of ‘subluxation’ on their website, including:

Subluxation is a disturbance in one or more of the joints of the body; in particular, a disturbance in the spine can interfere with the function of the nervous system.

The Subluxation

Subluxation may occur as the result of injury, compensation for injury, or as an effect of normal adaptation to physical and non-physical stressors and influences. Clinical indications for the diagnosis of subluxation may include:

  • Pain
  • Asymptomatic functional distortion
  • Postural abnormalities
  • Clinical conditions or end-organ manifestations of abnormal nerve function that are either mediated or affected by spinal segmental nerves
  • Clinical conditions that are created by normal compensatory mechanisms in response to injury, trauma, or abnormal stresses (Source, cached)

They even held an on-campus seminar entitled How Big is Your Subluxation (cached) last week!

Trade associations

The Scottish Chiropractic Association seem to be trying to dodge the issue by saying:

Spinal vertebrae can become misaligned or fixated causing interference to the joint and its associated structures. Chiropractors have historically referred to these as subluxations. Many synonyms (joint blockage, joint dysfunction, aberrant articulation) exist for this theoretical model which can cause pain, restriction of mobility, imbalance and many other symptoms.  Chiropractors specialize in locating and then working with patients to correct these problem areas. (Source, cached)

The United Chiropractic Association appear to have been a bit more diligent and many pages using the ‘S’ word have now been removed, but it’s not that long ago that they stated:

In simplest terms, a subluxation (a.k.a. Vertebral Subluxation) is when one or more of the bones of your spine (vertebrae) move out of position and create pressure on, or irritate spinal nerves. Spinal nerves are the nerves that come out from between each of the bones in your spine. This pressure or irritation on the nerves then causes those nerves to malfunction and interfere with the signals traveling over those nerves. (Source, cached)

The McTimoney Chiropractic Association have similarly removed all mentions of the subluxation from their website, but it recently said this in an anecdote:

On examination I found a subluxation apparent at L2, with the pelvis rotated left posterior, right inferior tilt and left ASIS superior. Subluxations were also apparent at T2, T5 and T9. I found Georgia’s symptoms were consistent with pressure on the obturator nerve, and proceeded to make standard McTimoney adjustments to correct the pelvic misalignment and the vertebral subluxations. (Source, cached)

The British Chiropractic Association say nothing about it now, of course, but recently removed their leaflet Servicing your spine, the text of which can be found here (cached):

As you go through life, a loss of proper function (movement) in the vertebrae, which some chiropractors call a subluxation, may interfere with the healthy working of your spine and the nerves that run through it. This may affect your body’s natural ability to recover from injury and you may find yourself increasingly unwell, unable to shake off apparently minor aches, pains and even some illnesses.

The big divide

Listen to some on one side of the subluxation divide and you’d get the impression that not one single chiropractor in the UK believes in subluxations any more than they do in Santa Clause; others vehemently defend the subluxation as the essential foundation of real chiropractic.

Indeed, a Google search for “chiropractic clinic subluxation” restricted to .uk domains, returns nearly 2,500 pages. Not all are chiropractors websites, but it does show there are significant numbers of then still claiming this now outdated concept as a reason for your ill-health and for lightening your wallet through ‘wellness’ or ‘maintenance’ chiropractic care:

Nearly any kind of stress can cause a subluxation: a fall or an accident (even a very small one that happened years ago); a poor sleeping position; poor posture; fatigue; emotional stress; poor nutrition or a combination of stresses. A subluxation need not happen all at once. It could set in the body over time. (Source, cached)

Evidence of vertebral subluxations in the upper cervical spine was found in every patient. (Source, cached)

Since many subluxations in infants are in the upper cervical area, there is a strong possibility, especially when there has been a history of birth trauma, that these babies are suffering from head and neck pain due to spinal subluxations in this area. (Source, cached) [Note: this website is still making claims about colic]

A subluxation is a spinal bone out of alignment which causes interference to the nerve system, adversely affecting one’s overall health and wellbeing. (Source, cached)

Cracklash

The ‘straight’ chiropractors are not taking this lying down: the battle lines have been drawn, the first salvoes of revolt have now been fired and past cracks are beginning to re-open.

Following on in a grand tradition, I hereby dub this the Cracklash.

The United Chiropractic Association devoted five pages of their summer 2010 newsletter (cached) to defend the beleaguered subluxation, claiming that the subluxation is “a very real and verifiable entity”, citing US State and Federal laws, the Foundation for Vertebral Subluxation (yes, it has its own website), and a plethora of chiropractic organisations. But not much evidence.

It also looks like they are trying to make the most of the current state of affairs by trying to coax new members to their side, ready to do battle.

Then there was the aforementioned Foundation for Vetebral Subluxation. Their President, Christopher Kent, penned An Analysis of the General Chiropractic Council’s Policy on Claims Made for the Vertebral Subluxation Complex (cached).

The website introduction says:

The management of vertebral subluxation has been the chiropractic profession’s unique contribution to the healthcare system for 115 years.

Unique contribution to healthcare?

Kent accuses the GCC of building straw men and resorting to special pleading. But most of his article consists of a textual analysis of the GCC’s statement and a denigration of RCTs. Oh, and building straw men and resorting to special pleading.

But he does ask one very pertinent question:

Are we a profession with a clearly defined mission or are we a profession simply seeking some niche which offers access to a slice of the health care pie?

Something for all to ponder as we watch, from the sidelines, the Cracklash unfold.

I’ll bring the popcorn.

22 Responses to The Cracklash begins

  • Thanks for more intriguing revelations, Zeno.

    I’m glad to see the GCC’s recent statement (“there is no clinical research base to support claims that the chiropractic vertebral subluxation complex is the cause of disease or health concerns”) being aired again, because I would remind readers that in 2004, Margaret Coats, CEO of the GCC, claimed that there was “scientific evidence” for the *many* interpretations of the word ‘subluxation’. See point 4 here.

    What happened to that scientific evidence remains a mystery.

  • They can detect and correct my bony subluxation any day.

  • Zeno is surprisingly quick and adamanant (again- see obituaries) in his interpretation of the word “historical” to mean “just an historical concept, consigned to the history books as an outdated and irrelevant concept that explains absolutely nothing and based on no evidence whatsoever; something dreamed up 120 years ago by a magnetic therapy salesman”.
    I think Zeno may need to rethink his interpretation of the word historical rather than eat too much popcorn…
    It could ofcourse also just mean “someone came up with it in the past, recorded it and now we’ve moved on (even if we have done so without producing much evidence)”.
    A little like most scientific processes really… someone says something, and the next one either disproves it or improves on it until the day breaks that a workable and testable format arises… Good luck with it all zeno
    Kind regards,
    Stefaan Vossen
    This is only the beginning

  • “What a hornet’s nest we stirred up, with the GCC eventually acknowledging that chiropractic had to be based on proper evidence and not on wishful thinking.”

    Dear Zeno,
    I know this goes dead against this seemingly hermetic view of the world you hold, but Chiropractic doesn’t “have to be based on proper evidence” and is in fact allowed to include plenty of wishful thinking…that is after all what the vast majority of most healthcare interventions are based on. Whatever you and your compadres/madres think. What does however have to be based on proper evidence is claims made by chiropractors as they have to be vetted and approved by the ASA’s rules. And the GCC has to play by those rules, and make sure that we play by those rules too.
    If your efforts were directed any further than enforcing ASA rules in regards to “claims chiropractors made”, then I am afraid to say you still have some work to do… maybe you could set up a study to assess whether or not you can find any scietific evidence that the chiropractic subluxation theory doesn’t work? Ah, but you’ll have to work out what that theory really is first…
    Stefaan

  • Stefaan wrote: “…[chiropractic] is in fact allowed to include plenty of wishful thinking…that is after all what the vast majority of most healthcare interventions are based on. Whatever you and your compadres/madres think.”

    Nonsense. Bearing in mind that the General Medical Council’s rules have always stated that MDs’ “information must be factual and verifiable”…

    QUOTE
    “Good Medical Practice: Providing and publishing information about your services

    1. 60. If you publish information about your medical services, you must make sure the information is factual and verifiable.

    2. 61. You must not make unjustifiable claims about the quality or outcomes of your services in any information you provide to patients. It must not offer guarantees of cures, nor exploit patients’ vulnerability or lack of medical knowledge.

    3. 62. You must not put pressure on people to use a service, for example by arousing ill-founded fears for their future health.”

    http://www.gmc-uk.org/guidance/good_medical_practice/probity_information_about_services.asp

    …it is clear that as much as 80% of modern medicine is evidence based:

    http://www.theness.com/neurologicablog/?p=51

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314867/pdf/15160706.pdf (pp4-5)

    http://www.dcscience.net/garrow-evidence-bmj.pdf

    http://www.bmj.com/cgi/eletters/335/7623/736-a#178246

  • “Many synonyms… exist for this theoretical model… Chiropractors specialize in locating…”

    I like that bit. It sounds like being trained to find (theoretical) spirits in (theoretically) haunted houses. Only some people are able to (theoretically) do it properly.

  • @Blue Wode
    “Nonsense. Bearing in mind that the General Medical Council’s rules have always stated that MDs’ “information must be factual and verifiable”

    How does that make it nonsense for a clinician to acknowledge that
    a)less than 20% of medical practices meet EBM standards
    b)the clinician looks at what is in front of him/her, formulates a theory and then hopes it all works out to at least seem correct.
    Post -rationalisation and all that…
    Information, yes, that should be factual and verifiable as it says in the GCC statement and the GMC statement you’re quoting alike, but that has nothing to do with the working model, and certainly nothing to do with the rest of my statement which clearly refers to the interventions, and NOT to “information”.
    You may wish to think that the two are the same, but that is where you couldn’t be more wrong…
    Concept, working model, information,… three different things.
    That is where your lack of clinical experience is letting you down.
    Stefaan Vossen
    This is only the beginning

  • Stefaan Vossen wrote: “Information, yes, that should be factual and verifiable as it says in the GCC statement and the GMC statement you’re quoting alike, but that has nothing to do with the working model, and certainly nothing to do with the rest of my statement which clearly refers to the interventions, and NOT to “information”.

    But Section B2.7 of your Code of Practice requires that you [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.”

    It begs the question, what sort of information are you giving patients about the interventions you are using?

    Could it be that you are twisting Section A2.3 of the GCC’s Standard of Proficiency, which states clearly that “Chiropractors’ provision of care must be evidence based”, to allow “in my experience” and “the patient likes it” to be considered along with evidence, effectively negating the whole point of evidence-based medicine? See here:

    http://www.sciencebasedmedicine.org/?p=5339

  • @Bluewode
    ps 80% is possibly a little adventurous, particularly if we start taking into account the placebo effect of being in a medicalised environment….
    I know this is mischief but the point still stands: EBM is EBM, RCT’s are RCT’s and EBM includes amongst others RCT’s logic and common sense. Chiropractors apply primarily the two latter on a broad and in-depth knowledge-base of anatomy, neurology and physiology amongst others. The fact that there isn’t much in terms of RCT support does not by any stretch of the imagination mean that chiropractic practice is not evidence based… unless you still think we’re talking about cancer and asthma and tetanus and not like most chiropractors in this country: backpain, or unless you think that EBM = “RCT-based medicine” (trust me Steve’s account of EBM certainly takes a broader view). I don’t think you have got your research base on chiropractic sussed out… or chiropractic in fact, come to think of it.
    Stefaan

  • @ Stefaan

    You’re not making yourself clear to me. Are you saying that you base your evidence on your clinical experience, i.e. what you see with your own eyes?

  • @BW how do you deduce from what I am writing that I “base my evidence” on my clinical experience? Evidence is evidence, clinical experience is clinical experience… What is this evidence you refer to in your statement for? The evidence I base my information for patient-discussion on? Or is it my evidence required by the ASA for advertised claims?
    Stefaan

  • Stefaan

    “@BW how do you deduce from what I am writing that I “base my evidence” on my clinical experience?”

    It looks to me like Blue Wode is *asking* you what you base your evidence on and he’s not made the assumption you jumped to.

  • @IainD
    my evidence to base what on? As I stated in my response to BW, that is the question. What assumption did I jump to?

  • Thank you, IainD, for clarifying my previous comment.

    @ Stefaan Vossen

    I don’t find it easy to comprehend your comments.

    Interestingly, Zeno highlighted a very pertinent question made by Christopher Kent, President of the Foundation for Verebral Subluxation:

    Quote
    “Are we a profession with a clearly defined mission or are we a profession simply seeking some niche which offers access to a slice of the health care pie?”

    I think that gets near to the hub of the issue, i.e., are chiropractors evidence-based or anecdote-based? They cannot be all things to all people. Whether claims are advertised, or made in a clinical setting (upon which, it follows, treatment will be administered), one would expect them to be backed up with good, scientific evidence and a favourable risk/benefit profile.

  • Stefaan

    “@IainD
    my evidence to base what on? As I stated in my response to BW, that is the question. What assumption did I jump to?”

    Eh? I assume you’re just confused, but, as I said in my last comment, you said:

    ““@BW how do you deduce from what I am writing that I “base my evidence” on my clinical experience?””

    But Blue Wode did not say that he deduced that you based your evidence on your clinical experience – he *asked* you if you did. It was a question, not a statement. The question he asked was:

    “Are you saying that you base your evidence on your clinical experience, i.e. what you see with your own eyes?”

  • @Blue Wode
    I am having some trouble understanding you too, I guess we are cross wires at the moment.
    That said I do think that the fetish held here for RCT’s is disproportionate and not representative of clinical reality (in any healthcare field), in the same way as equating the GCC’s statement to anything but an agreement that the vertebral subluxation concept is an historical, but still valid theoretical model which is lacking in RCT-evidence.
    The other thing we (you and me) seem to be getting crossed is the idea of what this subluxation concept is… what do you understand it to be?
    Stefaan

  • Stefaan, have you contacted the GCC about what they really mean the chiropractic subluxation to be?

    As far as my understanding of the chiropractic subluxation goes, I get the distinct impression that it’s whatever chiropractors want it to be.

  • Blue wode rightly asks “What happened to that scientific evidence remains a mystery”. The GCC Chief Executive Margaret Coats also wrote to me claiming “The GCC subluxation was based on the WHO definition and 160 people, including experts and national authorities and professional and NGO’s, in over 54 countries had reviewed this document prior to publication”

    So its fair to say the GCC is not a reliable source of information for a debate on subluxation and to quote from them only undermines any discussion questioning the existence of subluxations which are documented both in the medical and chiropractic literature.

    The medical profession recognise subluxation in relation to hypermobility of a spinal joint so presumably dysfunction also applies to hypo mobility of a joint or am I mistaken?? The question sceptics have every right to ask; what is the scientific evidence for the theory behind “vertebral subluxation complex” and sadly I would have to hold up my hands and say, not a lot.

    Before sceptics get too excited I would qualify that by saying the anatomical and physiological principles are there to make subluxation theory a legitimate hypothesis for scientific investigation and I would be delighted if chiropractic researchers put some of their resources into subluxation theory rather than the more profitable area of back pain. In the mean time my clients and I will just have to rely on anecdotes, not a perfect situation, but if they are happy with that so am I, we are where we are.

    Having said that the president of the British Chiropractic Association Richard Brown has this week come out in agreement with the skeptic view of “subluxation”. As his “plethora of evidence” was rubished last year. I dont suppose traditional chiropractors should be too worried by anyone now trying to claim that Richard Brown is a reliable source because it suits a particular point of view. I believe thats called “confirmation bias”

    The medical profession were making dodgy claims in 1998, perhaps they have cleaned up their act, better than the BCA did,
    http://ukpmc.ac.uk/articles/PMC1113581

  • @Blue Wode
    I think you’ll find the GCC fairly non-judgmental on this topic, but by all means ask them. I would love to know what you personally understand it to be though. Having looked into the topic so extensively I would expect you to be quite knowledgable on what it is you critique. It would just make conversing without cross-wires so much easier.

  • ps I think it can be quite releveant when asking for “the scientific evidence” for me to ask the question: scientific evidence for what?” And if your answer is “the subluxation theory”, the I do, indeed want to know what your understanding of this theory is, as depending on your interpretation/understanding of it it will be easy/difficult/impossible to provide you with information/evidence.
    Kind regards,
    Stefaan

  • @BW
    Another BlueWode #fail?
    You know, you are only feeding the suspicions of malice in avoiding constructive debate…
    Maybe that is just not your goal, that could be true of course. That does of course make you a heckler, rather than a skeptic.

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