The random thoughts of a sceptical activist

The beginning of the end? Part two

Last time, I said I’d have more to say on the letters I’ve received so far.

I said that seven of the 36 were dismissed because the chiropractors mentioned on the websites were no longer at that clinic and therefore — by the GCC’s reckoning anyway — were no longer responsible for claims made. My arithmetic was faulty; there were eight, leaving 35 others. I’ve corrected the previous blog post.

This post deals with why the Investigating Committee (IC) decided there was no case to answer in most of these 35.

Sciatica

The vast majority of the 35 had made claims about sciatica — it was claimed on 31% of the sites I included in my complaint. (There will be more on sciatica in a future blog post.)

The IC said:

The Investigating Committee noted from the [Bronfort] report that there is no high or moderate positive evidence from randomised controlled trials that would support an advertised claim regarding sciatica using manual therapy.

Nothing unexpected there. But the attentive reader will know by now that it may not always be that simple:

In the light of this, the Investigating Committee concluded that it could be inappropriate for you to make such an advertised claim.

It ‘could be inappropriate’ to make a claim not supported by good evidence??? When might it be appropriate???

However, having found evidence that the chiropractor had indeed made the claims I was complaining about and having decided that there was no robust evidence to substantiate that claim and that it could be ‘inappropriate’ for them to make such a claim, did they decide there was a case to answer?

In these circumstances, and having taken all the information before it into consideration, the Investigating Committee has concluded that the facts of this complaint, taken at their highest, would not be capable of amounting to unacceptable professional conduct and therefore there is no case to answer.

The key phrase here is ‘unacceptable professional conduct’.

Clause 20.—(2) of the Chiropractors Act 1999 defines this term:

In this Act conduct which falls short of the standard required of a registered chiropractor is referred to as “unacceptable professional conduct”.

So a chiropractor, making a claim for which there is no evidence is not considered to be unacceptable professional conduct and therefore has no case to answer. Such conduct does not fall short of the required standard, apparently.

This does not bode well.

When is a list of conditions not a claim to treat those conditions?

Taking one of them as an example, a chiropractor had stated on his website (cached) — and in fact, still makes exactly the same claims:

Chiropractors successfully treat a wide variety of problems such as back pain, neck pain, sciatica, trapped nerves, sports injuries, head-aches, car accident neck sprain injuries, leg or arm pain, stiff joints and wear/ tear, repetitive strain injuries (RSI’s) and muscle tension problems.

They are clearly making a claim that chiropractic treats sciatica (I’ll come to the other claims later) — and the GCC agrees.

But many websites never actually used the word ‘treat’ or ‘cure’ or anything similar. Many just had a list of conditions.

Like this clinic in Leicester. This website has been completely demolished and no longer exists, access in archive.org has been blocked, and the domain registration has just expired, but this is one of the pages I submitted to the GCC:

A list of medical conditions, but no help/treat/cure/ease/alleviate symptoms or other woolly weasel words. What message is the reader intended to take from that list?

If these chiropractors aren’t claiming they can in some way influence those particular conditions, what’s the list for? Is it a list of the conditions the chiropractors themselves suffer from, perchance?

Anyway, how did the IC deal with this one?

They said the list was a list of conditions, but decided:

…however it was not clear from the website extract provided whether you made a publicised claim to treat sciatica on your website.

Sorry? What isn’t clear, exactly?

I have little doubt that the ASA would consider such a list of conditions as a claim to treat those conditions. As I’ve pointed out before, the ASA cover implied claims as well as direct ones (clause 3.1 of the CAP Code). But then again, the IC don’t seem to be at all interested in what the ASA have to say on anything, despite the CoP mandating that chiropractors follow their guidance.

Pathetic excuse #1

Well, if the IC weren’t clear about something, it might be an idea to ask the chiropractor concerned what he/she meant.

It did cross their minds:

The Committee considered whether it should ask you to provide further information about these references as they appeared on your website,

Good (but you know there’s a ‘but’ coming):

…but was mindful that due to the passage of time that has elapsed since the complaint was submitted, it could not be certain that any web pages as they appear now would be the same as when the complaint was submitted.

Yes, it all happened a long time ago…

The Committee concluded that there is insufficient evidence available to it for it to consider this matter further.

Because it all happened a long time ago, they gave up.

Anyone spot the non sequitur: “The IC considered whether it should ask about the references as they appeared on the website, but decided not to because the current site might not be the same”?

Is that really the best excuse they can come up with?

Real reasons?

I’m open to suggestions as to why the IC made this bizarre decision, but I note the chiropractors at this particular clinic include Tim Hutchful and Colin Rose, Secretary and Director respectively of the BCA.

I also note that five of the eight chiropractors on the IC are members of the BCA.

A case to answer?

There are some legal issues to be considered around this, but, for now, I’ll simply state what the Chiropractors Act 1999 has to say about the duty of the IC at this stage. It states that the IC shall:

…consider, in the light of the information which it has been able to obtain and any observations duly made to it by the registered chiropractor concerned, whether in its opinion there is a case to answer.

The Investigating Committee Rules 2000 say little more.

Have they applied these rules in this case? The phrase ‘information which it has been able to obtain’ does imply that they have to actively do something, but have they tried hard enough to gather information? We already know they rejected my comment document, although they said

The Investigating Committee did not consider that your letter raised any points that it had not given careful consideration to when making its decision…

Whether or not they have, the rules say nothing about not bothering to ask for information just on the off chance it might be a bit out of date.

But what about the other conditions?

A very good question.

In the first example I used above, the website made claims about many other conditions. To recap:

Chiropractors successfully treat a wide variety of problems such as back pain, neck pain, sciatica, trapped nerves, sports injuries, head-aches, car accident neck sprain injuries, leg or arm pain, stiff joints and wear/ tear, repetitive strain injuries (RSI’s) and muscle tension problems.

Surely these are conditions that Bronfort either didn’t find any evidence for or found there was no good evidence for?

Again, it’s not so simple.

The IC noted references to these conditions (although, bizarrely, a slightly different list):

The Investigating Committee noted the reference to trapped nerves, sports injuries, trauma injuries, leg and arm pain, stiff joints and wear/tear, repetitive strain injuries, muscle de-conditioning problems, neck sprain injuries and muscle tension problems. It concluded that such terms are broad in nature and the pages provided do not enable the Committee to understand what is covered by the use of these terms.

So they have refused to consider these because they couldn’t understand what the chiropractor meant by them. However, they went on to repeat the nonsense about not bothering to ask the chiropractor for further information

Because these ‘broad’ terms were not mentioned specifically by Bronfort, doesn’t that mean that there is no good evidence for them and therefore — by the GCC’s own argument — should not be being claimed by chiropractors? In their guidance on advertising, they say:

…any claims you make must be based on best research of the highest standard.

So, where’s the ‘best research of the highest standard’ for trapped nerves, RSI, neck sprains, etc, etc?

ASA guidance

As I mentioned in Part one, the IC did not, in the letters, refer to the ASA guidance their chiropractors are supposed to adhere to, and provided no explanation for this omission.

Given that guidance and their past adjudications, I am convinced that, had the IC followed ASA guidance, they could not possibly have come to these bizarre conclusions.

Robust guidance, properly and diligently applied is what is needed to properly protect the public, not the feeble excuse that “it wasn’t really a claim to treat, but anyway, we don’t really know what they meant therefore we give up”.

Did they even consider all the evidence?

The Committee carefully considered the complaint made by Mr Henness and all of the documentary evidence provided to it, as set out in Appendix 1.

Appendix 1 listed:

  1. Letter of complaint with enclosures
  2. Website extract(s) provided by the complainant
  3. Your observations on the complaint

What about the evidence I provided to the GCC? Have they considered that — particularly what I said about the proper application of ASA guidance? Despite promises, I strongly doubt it.

Much more to come

But don’t worry, there is more to come. Much more.

I’ve still to be told about the other 500-odd cases. Even the best whitewash might not be white enough.

Going by the 72% of Simon Perry’s complaints that have so far been passed on to the PCC, I don’t think any chiropractor should be too heartened by this first round — a round that is by no means over.

http://network-tools.com/default.asp?prog=whois&host=londonroadchiropracticclinic

94 Responses to The beginning of the end? Part two

  • It’s a whitewash all right and confirms that the chiropractic ‘profession’ is utterly corrupt from the top down.

  • I have no idea of how the IC works, but if all of the IC members have one equally weighted vote regarding whether any complaint should be upheld or even dealt with, then I guess it’s always going to be an outcome of at least 8 to 4 in support of chiropracty.

    The more I read about chiropracty, the more I become convinced there is no logical reason why it should exist (apart from to provide chiropractors with a job). Providing patient choice and offering drug/surgery free alternatives? Sorry, that’s just words. As far as I understand it, the evidence is simply not that strong that basic chiropractic malarkey works, beyond simple placebo effect, for anything! I’m sure some of the things that chiropractors suggest do help, such as weight advice and exercise and stretching etc. But I fail to see how this can possibly justify how they have set themselves up as ‘health care professionals’ entitled to use the title of doctor.

    I think that brilliant quote that Zeno found from Christopher Kent sums up chiropracty so well, “…are we a profession simply seeking some niche which offers access to a slice of the health care pie?” Surely this is an Emperor’s new clothes kind of question – Of flipping course they are! And they haven’t found it yet!

  • Zeno,

    Have you any news on comment on this message that “We’re all Doomed” left on your last post:

    “Just found out that the GCC, after taking legal advice, cannot go ahead with your complaints. Any conditions which they were promoting/endorsing at the time of your omnibus complaint prohibits them from disciplining those chiros that were simply following their example.”?

  • David

    You’ll need to wait for my next blog post.

  • Thank you for another intriguing post, Zeno.

    Even if the GCC were to keep a tight check on claims made by chiropractors by applying proper ASA guidance, patients would still not be protected from the chiropractic ‘bait and switch’: http://www.dcscience.net/?p=1516

    Although we know that the GCC has recently ruled that the chiropractic vertebral subluxation complex is an historical concept and that it is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns, its definition of evidence-based care remains as follows:

    Quote
    “…clinical practice that incorporates the best available evidence from research, the preferences of the patient and the expertise of practitioners, including the individual chiropractor her/himself.”

    Unfortunately, that allows for quackery such as Applied Kinesiology and Craniosacral Therapy to fall within its definition. See here:
    http://jdc325.files.wordpress.com/2009/06/gcc-ak.pdf

    Since the vast majority of chiropractors in the UK work in private practice, I think it’s high time that the public was told that although the GCC has influence over chiropractors’ advertising, it has no real powers to limit chiropractors’ scope of practice, and that, as a consequence, patients are in real danger of wasting their time and money on useless (and in some cases, potentially lethal) treatments.

  • @ Zeno,

    Thank you; I shall be interested to hear what they have said.

  • Zeno,

    This is not meant to be an argumentative or personal comment, so please don’t read it as such. It is simply a matter of relevence to the topic.

    I made a comment on your last post about the contributions made by Blue Wode and I have to say that I believe it applies as much to this latest one as any of the previous ones:

    “Can you see a pattern to Blue Wode’s contributions to this blog? It seems quite obvious to me that his/her sole intent is to denigrate chiropractic at any and every opportunity, shoehorning irrelevant quotes and references in wherever possible.

    One really has to wonder what the motive is. Personally, I find it hard to believe that it’s public interest; it has all the hallmarks of pure malice as far as I can tell.”

  • David

    Which bit of Blue Wode’s comment do you think is not relevant to the topic of the regulation (or otherwise) of chiropractors?

  • @ David

    You can read the GCC letter sent to Chiropractors on Richard Lanigan’s blog

    http://www.chiropracticlive.com/?p=790

  • The GCC do not have to punish those chiropractors who have made unsupportable claims. Simply telling them to not make such claims, and enforcing that (watching, warning, with potential punishment for repeat offenders) would be major progress.

    The investigating committee seems to have failed in its role, because making unsupported claims is a breach of Advertising standards rules, and breaking Advertising standards rules is a breach of GCC code of conduct. They seem to have actually made the standard be “worth punishing” rather than “a case to answer” or even their watered down (and highly dubious) modified version of “reasonable prospect of success”.

  • @Davidp
    the only reason for the GCC’s failure to enforce ASA rules is that it was in breach of these rules itself. Therefore enforcing these rules would mean possible litigation supported by the fact that chiropractors were only following example. As I said many times before, I really do believe that the majority of chiropractors (very few of which will actually treat for all these claims) were merely following example of list of claims from most authoritative source.
    @Blue Wode
    the GCC has not “ruled” that the subluxation concept is an historical concept and that it is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns. It is just stating the obvious: It’s a concept without scientific evidence. Sorry, but the way you are making the comment just sounds like you actually think the term “historical” means “without value”. As I stated to Zeno, before, it is an historical concept, always has been and always will be until the evidence emerges to support at least parts of its original theory, if it ever emerges. The rest is just emotive. Also your critique of the GCC’s definition of EBM is just obscene; take a look at the GMC’s definition, it’s quasi identical and for very good reason as any more restrictive would pretty much put all healthcare flat on its bottom and render it useless.
    Lastly you comment that as a consequence of the GCC’s inability to limit scope of practice the public might be at risk of wasting their time and money on useless (and in some cases, potentially lethal) treatments. Could you please provide some references or reasoning behind this? Do you have any knowledge of success or risk stats to back this up? And would you be able to tell us all how that this has anything to do with the GCC’s scope of practice? Advertising standards and scope of practice are very different things. Some chiropractors made statements they shouldn’t have had they looked at the research available. THey didn’t they looked at the GCC-errore humanum est. The fact that research is not available for something does not mean that they have not had great success with the treatment. It just means there is no research (to support or reject I hasten to add). Which is why you will find that most of us have great reputations, great practices and the work comes to us by word of mouth rather than websites or advertisements. Helping primarily chronic back pain, at an average cost of £320 per case and a success rate of %98 doesn’t seem like “a waste of time and money on useless treatment”. That said, please do let me know if you actually have anything to back up your claims to the contrary. If you haven’t, then your opinion is as good as any chiropractor’s and you will have to agree on being equal. I on the other hand can back up my claims…
    Stefaan Vossen
    This is only the beginning

  • @ Stefaan Vossen

    You wouldn’t happen to be posting as ‘rwk’ or ‘nwtk2007’ in the comments section here:
    http://www.sciencebasedmedicine.org/?p=5897

    It looks they are also not finding it easy to understand the points being made.

    As for all your questions, you’ll find the answers to them here:
    http://www.ebm-first.com/chiropractic.html

  • @ Blue Wode,
    no, I post under my own name, always. The website you refer to spawns the usual drivel which does not answer the questions at all, but then this is not your aim after all is it?
    http://www.chiropracticlive.com/?p=794
    Stefaan Vossen Doctor of Chiropractic

  • @Blue Wode
    I suggest you reflect on your motives and understandings of what chiropractic is. It is customary for people to study their topic prior to critiqueing. At least if they wish to be taken seriously, otherwise, as I already observed to you, it would make you nothing more than a heckler. Could you please answer my questions to you? The information your provide does not answer the questions. If you need further clarification as to their meaning, please feel free to ask.
    Stefaan

  • @Blue Wode,
    on the one page you referred me to alone there are (at least) misquotes in relation to the SCA and McT, decontextualisations in relation to “allergies” and “chiroquakery” and very questionable references and unattributable quotes in relation to “vaccinations”.
    Sorry, but you’re no skeptic, you’re a quack, representing yourself to be something you’re not, you are misleading the public by attributing yourself to hold the skeptical stance and should be taken through ASA for misleading the public by saying you’re a sceptic when you’re not and in the process possibly risking people wasting valuable time and money on useless treatments as they have been dissuaded to try effective and efficient chiropractic care…
    Just busting some balls
    Stefaan

  • @BW, your site is down! don’t worry I have a cached version of it if you’d like…

  • @ Blue wode
    I’m rwk not nwtk2007. I find it easy to understand what’s going on ( SBM blog) as I’ve been in practice for 20 years. I’ve worked as a locum tenens for greater than 50 other chiropractors and
    I believe I have a right to make comments on the state of everyday practice. I have not seen nor caused a stroke. I’m pretty much amazed at how many lay people there are here and other blogs
    that are now experts on chiropractic because they read Trick or Treatment and a few other things.
    It’s the same argument back and forth. No winners here. By the way Bronfort is going to be giving
    a lecture on EBM at my alma mater,NUHS ( yes,a university with a chiropractic school) and I’ll be
    sure to let him know BW,Zeno and the rest all said hiya.

  • Robin wrote: “I have not seen nor caused a stroke.”

    You cannot know for sure that you haven’t caused a stroke…

    Quote
    “Sometimes the damage is immediate and the patient collapses on the chiropractor’s table. Sometimes mild symptoms start immediately and progress after the patient leaves the chiropractor’s office. Sometimes the tear is a small one and it clots over; then days later the clot breaks loose, travels to the brain and causes a delayed stroke. By this time, the patient may not connect his sudden collapse to the previous visit to the chiropractor.How often can a stroke be attributed to neck manipulation? We really don’t know. Estimates have varied from one in ten million manipulations to one in 40,000. I should clarify that only one specific type of stroke, basilar stroke, has been linked to chiropractic. It has been estimated that about 20% of all basilar strokes are due to spinal manipulations. This would work out to about 1300 a year in the U.S. But we just don’t know, because it has not been properly studied. Carotid artery strokes have also been reported after chiropractic treatments. Chiropractors do not follow up on every patient. Patients who have delayed strokes may never see their chiropractor again, so chiropractors would naturally tend to underestimate the risk. Many of these diagnoses are missed because the vertebral arteries are not typically examined on autopsy.”
    http://www.sciencebasedmedicine.org/?p=94

    Robin wrote: “By the way Bronfort is going to be giving a lecture on EBM at my alma mater,NUHS ( yes,a university with a chiropractic school) and I’ll be sure to let him know BW,Zeno and the rest all said hiya.”

    Would that be the same Bronfort who serves on the NCCAM’s National Advisory Council for Complementary and Alternative Medicine (NACCAM)?
    http://nccam.nih.gov/about/naccam/roster.htm

    Because if so, the Skeptic’s Dictionary has this interesting observation to make about the NCCAM:

    Quote
    “We’ve been waiting for 16 years for the NIH to announce some major breakthrough in health care that has emerged from NCCAM. Unfortunately, most of the “alternative” research is driven by faith, hope, and ideology rather than science. As Dr. Wallace Sampson noted: the NCCAM “is the only entity in the NIH [among some 27 institutes and centers] devoted to an ideological approach to health.”
    -snip-
    News stories
    $2.5 billion spent, no alternative cures found (big, government-funded studies show alternative health treatments work no better than placebos. “It’s the fox guarding the chicken coop,” said Dr. Joseph Jacobs….”This is not science, it’s ideology on the part of the advocates.”)
    Critics Object to ‘Pseudoscience’ Center (“The impending national discussion about broadening access to health care, improving medical practice and saving money is giving a group of scientists an opening to make a once-unthinkable proposal: Shut down the National Center for Complementary and Alternative Medicine at the National Institutes of Health.”)
    http://www.skepdic.com/NCCAM.html

    Hardly reassuring, is it?

    BTW, I see the NUHS (Robin’s alma mater) has a large acupuncture program:
    http://www.nuhs.edu/show.asp?durki=17

    That’s surprising to see when one considers that acupuncture is increasingly being shown to be little more than a theatrical placebo.

  • @ davidp

    “The GCC do not have to punish those chiropractors who have made unsupportable claims. Simply telling them to not make such claims, and enforcing that (watching, warning, with potential punishment for repeat offenders) would be major progress.”

    I agree. The GCC has got itself in a right mess. In their attempts to ensure that they are seen to be doing their job, they have bent over backwards to accommodate Mr Henness and are, at great expense, going to ridiculous lengths over this.

    The trouble is that the GCC’s own procedures demanded that they deal with the complaints in this way, each and every one being examined and processed in its own right. I’m sure that Mr. Henness couldn’t believe his luck when he realised how big his impact was on the GCC. I suspect that his reason for submitting 500+ complaints was originally an effort to demonstrate the extent of the problem as he saw it and to cause as many members of the BCA to be disciplined as possible. Let’s not forget that the stimulus for the complaints was an action of support for Simon Singh’s defence of his libel of the BCA. The purpose was to discredit the BCA and it’s members.

    A side effect was to potentially bring the GCC to its knees and I’m sure that there are many “sceptics” who would be pleased to see that happen, in the misguided belief that that would be some sort of victory. What they should remember though, is that without the GCC there would be no regulation of the chiropractic profession at all, returning it to the bad-old-days when anyone, with no training, qualifications, standards of proficiency or code of practice, could call themselves a chiropractor. How is that going to benefit anyone?

    I believe that the GCC, having already achieved one change in the law to allow them to consider these complaints without folding, should have sought another so that they could consider all the complaints as one, which I believe is what was intended. That would have allowed a determination on the issues much sooner, to the satisfaction, or otherwise, of all concerned.

    Of course, the GCC has made life more complicated for itself by not managing to follow its own guidance in relation to the conditions it has publicised the chiropractic management of. That’s embarrassing enough for me as a chiropractor, let alone for the GCC.

    Unfortunately, they are now committed to pursuing this matter in the manner they have started. Some (?many/most) chiropractors will be told they have no case to answer, which will be a relief to them but described as a white-wash by the “sceptics”. Others will be disciplined, and some will deserve to be, for intentionally misleading the public, and I have no problem with that.

    However, I come back to your point that the simplest, and I believe best, option would have been to consider and then clarify the situation for all chiropractors and the public, and then properly police it after that.

  • David wrote: “…the simplest, and I believe best, option would have been to consider and then clarify the situation for all chiropractors and the public, and then properly police it after that.”

    But how is that possible for the GCC to police such a situation when it has already declared in a letter to Action for Victims of Chiropractic, on 17th June 2004, that is not an inspectorate? See here:
    http://web.archive.org/web/20060924185126/http://www.chirovictims.org.uk/images/GCC+letter+Page+2+17+June+2004.pdf

    The current regulatory set up appears to leave it to patients to recognise false advertising (and when their treatment might be dangerous, bogus, or unnecessary).

    A new pro-active (rather than reactive), chiropractor-free, independent regulatory body appears to be what’s needed.

  • @ Blue Wode,

    I don’t agree. Once the GCC has put its house in order with regard to its own literature and correctly advised registrants with respect to their publicity material, it can remain largely reactive. This is the manner in which the General Medical Council and the General Dental Council operate and is the proper and appropriate manner for the GCC to operate as well.

    Let’s face it, there seem to be plenty of “sceptics” available, let alone patients, to report any non-compliance.

    The suggestion of a chiropractor-free regulatory body is ridiculous, as you know.

  • Two interesting articles that have arrived in my inbox this evening:

    1) “Further evidence has come to light suggesting that GlaxoSmithKline knew about an increased cardiac risk with the diabetes drug rosiglitazone (Avandia) as early as 2001 but withheld the data and that certain officials at the FDA conspired with the company to minimize the impact of later safety results”
    http://www.medscape.com/viewarticle/725012?sssdmh=dm1.626649&src=nldne&uac=148070PR

    2) “Physicians should not prescribe the malaria drug quinine (Qualaquin) for nocturnal leg cramps — an off-label use — because it may result in serious and life-threatening hematologic adverse effects, the US Food and Drug Administration (FDA) announced today……….. The FDA issued a similar warning in 2006, but the agency noted today that the majority of quinine used in the United States is still for the prevention or treatment of leg cramps.” http://www.medscape.com/viewarticle/724798?sssdmh=dm1.625757&src=nldne&uac=148070PR

    Relevant because of the issues of regulation and compliance.

  • David “The suggestion of a chiropractor-free regulatory body is ridiculous, as you know.”

    Why’s that ridiculous?

    There are always calls for complaints about the police to be handled completely independently of the police (they can always get any necessary advice from an expert if required) and the PCC to be completely independent of the press. Why should that not be the same for chiros?

    If there is a clear set of rules that have to be followed, then it doesn’t take a chiro to tell whether one of the rules has been broken. If specialist advice is needed about say xrays or whether some chiro technique technique was the right one, they can ask an expert. In fact arent the GCC in the habit already of paying chiros like Richard Brown to provide expert chiro testimony?

    Which bit of “you must only advertise consistant with the law and ASA guidance” does it need a registered chiro to decide on?

  • Yes, David. Wow! Big Pharma and MDs aren’t perfect either and need tighter control and oversight.

    Next!

  • @ JoeMac

    “David “The suggestion of a chiropractor-free regulatory body is ridiculous, as you know.”

    Why’s that ridiculous?”

    Considering that every aspect of regulation of the chiropractic profession is by definition going to involve chiropractic, it makes sense for chiropractors to be present on the GCC. However, it also makes sense for there to be lay members on the GCC, which is why there are lay members on the GCC.

  • @ JoeMac

    “Yes, David. Wow! Big Pharma and MDs aren’t perfect either and need tighter control and oversight.

    Next!”

    Yes Joe, my point precisely.

    Chiropractors are no better, AND NO WORSE, than MDs or Dentists, or Vets, or Osteopaths etc. So, there’s no justification for this vendetta against chiropractors?

  • David

    You seem to have completely missed my question:

    “Which bit of “you must only advertise consistant with the law and ASA guidance” does it need a registered chiro to decide on?”

  • David

    So Big Pharma and doctors are lying, cheating, killing megalomaniacs out to make money regardless of human suffering therefore it’s Ok for chiros to be as well? Don’t you want chiros to be better than the enemies so many of them despise?

  • @JoeMac

    The GCC have got rather more to deal with than simply ensuring compliance with ASA standards, although it is currently being prevented from doing much else because of a couple of well- publicised complainants.

    Are you seriously suggesting that the GMC should be a doctor-free organisation? Or, that dentists should be regulated by an organisation with no dentists involved?

  • @ JoeMac

    “So Big Pharma and doctors are lying, cheating, killing megalomaniacs out to make money regardless of human suffering therefore it’s Ok for chiros to be as well? Don’t you want chiros to be better than the enemies so many of them despise?”

    I have no idea where you got the notion that I consider doctors and drug companies in that fashion. I also have no idea why you believe that these people are my enemies. We are all working in healthcare and I hope, and believe, that the vast majority of my medical colleagues have just as much honesty, integrity and professionalism as I do.

  • It is absolutely clear that a good many chiropractors make claims that are not supported by evidence. This is a problem and I don’t see it being resolved anytime soon (even with the outstanding efforts made by Zeno and Simon Perry).

    So how about this for an idea: Individual Chiropractors no longer be allowed to advertise their services. All they may do is have a line entry in the white pages under the heading of chiropractors. (This should not affect Stefaan as he works entirely from referral and recommendation.) The GCC or BCA simply publish a list of all registered chiropractors and state the scope of chiropractic practice, as supported by proper scientific evidence. (i.e., they may possibly be able to help with a bit of lower back pain.)

  • David
    “The GCC have got rather more to deal with than simply ensuring compliance with ASA standards, although it is currently being prevented from doing much else because of a couple of well- publicised complainants.”

    So which sections of the COP do you think can *only* be decided by a chiro?

    A You must respect patients’ dignity, individuality and privacy
    B You must respect patients’ rights to be involved in decisions about their healthcare
    C You must justify public trust and confidence by being honest and
    trustworthy
    D You must provide a good standard of practice and care
    E You must protect patients and colleagues from risk of harm
    F You must cooperate with colleagues from your own and other professions

  • David

    I neither know nor particularly care what you think about doctors and drug companies or whether you think you’re working in healthcare. I wasn’t talking about you specifically – I was talking about some chiros who seem to intensely dislike medical doctors and those nasty drugs that they force on people. Perhaps I’ve looked at too many US chiro websites?

    As for honesty, integrity and professionalism does that include making claims about conditions for which there is not, and has never been, any good evidence?

  • @Blue Wode
    I see I got a cut and paste regurgitation from you:
    Blue_Wode on Fri, 11/20/2009 – 22:23
    Title: Chris Pickard, thank you for
    Chris Pickard, thank you for your comments.
    You say that over the past seven years you have treated 3,000 people, “none of whom have died of a stroke after being adjusted”. How do you know that? How do you know that patients that you’ve never seen again haven’t had a stroke as the result of being “adjusted” by you? Here’s the problem:
    Quote
    
“Sometimes the damage is immediate and the patient collapses on the chiropractor’s table. Sometimes mild symptoms start immediately and progress after the patient leaves the chiropractor’s office. Sometimes the tear is a small one and it clots over; then days later the clot breaks loose, travels to the brain and causes a delayed stroke. By this time, the patient may not connect his sudden collapse to the previous visit to the chiropractor…How often can a stroke be attributed to neck manipulation? We really don’t know. Estimates have varied from one in ten million manipulations to one in 40,000. I should clarify that only one specific type of stroke, basilar stroke, has been linked to chiropractic. It has been estimated that about 20% of all basilar strokes are due to spinal manipulations. This would work out to about 1300 a year in the U.S. But we just don’t know, because it has not been properly studied. Carotid artery strokes have also been reported after chiropractic treatments. Chiropractors do not follow up on every patient. Patients who have delayed strokes may never see their chiropractor again, so chiropractors would naturally tend to underestimate the risk. Many of these diagnoses are missed because the vertebral arteries are not typically examined on autopsy.”

    Much of what you say above is not referenced by Harriet Hall who of course is a skeptic

    You said,
    You cannot know for sure that you haven’t caused a stroke…

    Then neither can anyone who’s ever touched,examined or massaged someone else’s neck as well.

    And you don’t know how I approach (or don’t) a patient’s spine.

    I suggest that if it is your mission to take down chiropractic, you ought to spend some time
    in several offices. Go visit Stefaan. Then after after a lengthy observation you’d have the right to an opinion worthy of publishing.

    The reason I brought up Bronfort was that you skeptics look at his report to validate your opinion
    of chiropractic. We’ll see what he has to say in person.
    Why does the BMJ have an Acupuncture in Medicine journal if it were only a theatrical placebo?

  • @ Andrew Gilbey

    “So how about this for an idea: Individual Chiropractors no longer be allowed to advertise their services………..”

    Thankfully there are persons better qualified and postitioned than you to decide what is appropriate in terms of marketing. I’d suggest that compliance with ASA standards is amply sufficient and, now that the failure of some chiropractors to do this has been broought to the attention of the ASA and the GCC, I’m sure it’s only a matter of time before that is achieved.

  • @ JoeMac

    You haven’t answered my question. Are you seriously suggesting that the GMC should be a doctor-free organisation? Or, that dentists should be regulated by an organisation with no dentists involved?

  • @ JoeMac

    “I neither know nor particularly care what you think about doctors and drug companies or whether you think you’re working in healthcare. I wasn’t talking about you specifically – I was talking about some chiros who seem to intensely dislike medical doctors and those nasty drugs that they force on people. Perhaps I’ve looked at too many US chiro websites?”

    It’s abunbantly clear that you don’t know what I think about doctors and drug companies, or anything else for that matter. I suspect you’re right in that you have been paying too much attention to the wrong websites.

    If you don’t care what I (or any of my chiropractic colleagues) think, then that suggests that your presence here is simply to heckle rather than to debate.

  • Robin wrote: “@Blue Wode I see I got a cut and paste regurgitation from you”

    Yes, you did, but it was lifted from here:
    http://www.ebm-first.com/chiropractic/risks.html

    Robin wrote: “Much of what you say above is not referenced by Harriet Hall who of course is a skeptic”

    Harriet Hall is also a science-based, retired medical doctor. As for references, you’ll find plenty in the link above.
    Also, it’s worth remembering what the International Chiropractic Association’s 1981 confidential malpractice alert had to say on the subject of chiropractic neck manipulation and stroke:

    Quote
    “In stroke patients it is common for patients to have sudden symptoms which may include occipital pain, dizziness, slurring speech, incoordination and vomiting. All or any such symptoms may occur at the time of manipulation *or later*.”
    See pp42-43 here
    http://www.casewatch.org/mal/nette/claim.pdf

    Robin wrote: “You said, ‘You cannot know for sure that you haven’t caused a stroke…’ Then neither can anyone who’s ever touched, examined or massaged someone else’s neck as well. And you don’t know how I approach (or don’t) a patient’s spine.”

    I am talking about chiropractors in general. Fig. 2 in the link below serves to demonstrate why it’s not wise for patients to let chiropractors anywhere near their necks:
    http://ptjournal.apta.org/cgi/content/full/79/1/50

    Robin wrote: “I suggest that if it is your mission to take down chiropractic, you ought to spend some time in several offices. Go visit Stefaan. Then after after a lengthy observation you’d have the right to an opinion worthy of publishing.”

    Irrelevant.

    Robin wrote: “The reason I brought up Bronfort was that you skeptics look at his report to validate your opinion of chiropractic.”

    That is correct, but I would hasten to add that the report has yet to be thoroughly evaluated by impartial scientific experts. For example, there are already indications that it is seriously flawed:

    Quote
    “…it is clear that what counts for favorable evidence does not pass muster in scientific circles.

    For example, they claim the evidence for chiro treatment of enuresis (bed wetting) is inconclusive but favorable. That is their summary of two papers:

    Reed WR, Beavers S, Reddy SK, Kern G: Chiropractic management of
    primary nocturnal enuresis. J Manipulative Physiol Ther 1994, 17: 596-600.

    Leboeuf C, Brown P, Herman A, Leembruggen K, Walton D, Crisp TC:
    Chiropractic care of children with nocturnal enuresis: a prospective outcome study. J Manipulative Physiol Ther 1991, 14: 110-115.

    The latter (1991) study was un-blinded and uncontrolled, and concluded that chiro did not work. The former (1994) was tiny, and the treatment and control groups were not closely matched; and the treatment and control groups were not statistically different after treatment…The review is rife with such over-enthusiastic interpretations of literature, and non-chiropractic references.”
    http://forums.randi.org/showpost.php?p=5671829&postcount=32

    Robin wrote: “Why does the BMJ have an Acupuncture in Medicine journal if it were only a theatrical placebo?”

    Money?

    Quote:
    “The same motive that causes some vice-chancellors to bring their university into disrepute by awarding BSc degrees in subjects that are not only not science, but which are oftenly openly anti-science.”
    http://www.dcscience.net/?p=351

  • @ Blue Wode

    “You cannot know for sure that you haven’t caused a stroke…”

    As we know, chiropractors have been wrongly blaimed for causing strokes in patients who were already in the process of a vertebral artery dissection when they consulted the chiropractor.

    Remember, a close temporal relationship between events does not prove a causal relationship.

    I’ll remind you of a case I had some years ago:

    A 32 year old woman presented to me complaining of neck pain and headache. I won’t go into the whole history here, suffice to say that the nature of the symptoms and their onset, together with family history, past medical history and lifestyle features, led me to refer her to A&E. Unfortunately, when she was examined at A&E she was diagnosed with a migraine and discharged with analgesics.
    Next day she came to see me again, desperate for help with her pain. This time I referred her to her GP whom I telephoned to express my concerns. Unfortunately, the GP was typically dismissive but I believe that the patient went to see him anyway, as a result of my insistence to her.
    I’m not sure of the exact course of events that followed but I tried to contact the patient over the next couple of days and eventually spoke to her mother. Her mother told me that the patient had been admitted to hospital and had been diagnosed with a stroke. I contacted the hospital and spoke to the neurologist managing her who confirmed the situation. Tragically, the conclusion of the story is that the patient went on to suffer a further, larger stroke and died in the next few days.

    Thankfully, I had not treated this woman but this is the sort of event that results in chiropractors being blamed for causing strokes.

  • David wrote “…chiropractors have been wrongly blaimed for causing strokes in patients who were already in the process of a vertebral artery dissection when they consulted the chiropractor.”

    But the GCC claims that chiropractors are trained to watch for pre-stroke warning signs…
    http://www.docstoc.com/docs/4693363/The-Letters-Editor-The-Times-Pennington-Street-LONDON-July

    …so why would a chiropractor manipulate the neck of a patient who already had a vertebral artery dissection in progress?

  • @David

    Remember, there are quite a few cases on record of patients stroking out on chiropractors’ tables after neck manipulation.

    If those strokes weren’t due to neck manipulation, but were, as many chiropractors would claim, the consequence of vertebral artery dissections in progress, then why did the patients have their necks manipulated in the first place?

    Chiropractors can’t have it both ways.

  • @ Blue Wode

    Sadly, vertebral artery dissections are often not easy to recognise in their early stages. The presenting symptoms are most commonly neck pain and headache which, as we know, are problems that chiropractic is a proven and appropriate treatment.

    There is no evidence that chiropractors are any less able, or less likely to diagnose these cases than medical doctors and my example is a case in point. I had already alerted the patient and therefore the A&E department to the possible diagnosis but they failed to spot it. Had the patient not re-presented to me, the diagnosis would have been further delayed.

    In this case I was lucky, because I didn’t treat the patient and there could therefore not be any suggestion that I had been part of the cause. Unfortunately, there have been times when the diagnosis has been missed by the chiropractor as well as the “doctors” and the patient has received treatment before the complete picture became clear. Again, this close temporal relationship of events does not prove a causal link between the treatment and the stroke.

    Thankfully, these events are very rare and chiropractic remains a safe, effective and appropriate way of managing musculoskeletal disorders, including neck pain and headache.

  • David wrote: “…chiropractic remains a safe, effective and appropriate way of managing musculoskeletal disorders, including neck pain and headache.”

    Not so. As the hallmark intervention of chiropractice is spinal manipulation, it is apparent that chiropractors’ use of it is less judicial than other manual therapists (see Fig.2 in the link I posted in my comment above).

    The bottom line is this:

    Quote
    “The effectiveness of spinal manipulation for most indications is less than convincing.5 A risk-benefit evaluation is therefore unlikely to generate positive results: with uncertain effectiveness and finite risks, the balance cannot be positive.”
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1905885/

    David, you can argue with me all you want, but you cannot argue with the science.

  • @ Blue Wode

    You can present as much distorted science as you like, it doesn’t make you right. The graph in your post simply relates to the fact that chiropractors perform much the most manipulation that is done. Just as well actually, given that they are the ones with the best and most extensive training in how to do it safely and effectively. You have no evidence that chiropractors make use of manipulation in a less judicious manner than anyone else, only the opinion of a physiotherapist.

    As you well know, chiropractic is about a great deal more than manipulation, which is only one of many tools available to chiropractors and, when used, is combined with the other elements of best practice in the chiropractic management of musculoskeletal disorders and their effects on the patient’s health.

    It appears that I do need to keep on arguing with you because you keep trying to mislead and alarm the public with unjustified anti-chiropractic propaganda. I am not arguing with the science. The only problem I have with the science, is that there isn’t enough of it yet.

  • David wrote: “You can present as much distorted science as you like, it doesn’t make you right.”

    And which parts of the science I’ve presented to you do you think are ‘distorted’?

    David wrote: “The graph in your post simply relates to the fact that chiropractors perform much the most manipulation that is done.”

    But why do they do it when there are effective, safer, cheaper and more convenient options available? To me, it smacks of large-scale malpractice.

    David wrote: “Just as well actually, given that they are the ones with the best and most extensive training in how to do it safely and effectively.”

    Are you sure about that? The latest Cochrane review on spinal manipulative therapy for low-back pain claims the following:

    Quote
    “Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low-back pain were similar. Radiation of pain, study quality, *profession of manipulator*, and use of manipulation alone or in combination with other therapies *did not affect these results*.”

    David wrote: “You have no evidence that chiropractors make use of manipulation in a less judicious manner than anyone else, only the opinion of a physiotherapist.”

    And those of well-respected, impartial scientists, Simon Singh and Professor Edzard Ernst, who, after thoroughly examining *all* the evidence for chiropractic in their recent book, ‘Trick or Treatment? Alternative Medicine on Trial’, came to the following conclusion:

    Quote
    “There is no evidence to suggest that spinal manipulation is effective for anything but back pain and even then conventional approaches (such as regular exercise and ibuprofen) are just as likely to be effective and are cheaper…*We would strongly recommend physiotherapy exercises and osteopathy ahead of chiropractic therapy because they are at least effective and much safer*.”
    http://tinyurl.com/3abuchf

    David wrote: “As you well know, chiropractic is about a great deal more than manipulation…”

    And as you well know, anything other than a chiropractic ‘adjustment’ is not chiropractic. It’s physical therapy.

    David wrote: “I am not arguing with the science. The only problem I have with the science, is that there isn’t enough of it yet.”

    But chiropractic has had over 100 years to produce robust scientific data. The data that are now in have almost invariably concluded that chiropractic has nothing unique to offer, and that the only intervention that chiropractors can provide – which is backed up by weak scientific evidence – is spinal manipulation for the short-lived relief of pain in a sub-group of low back pain sufferers. Even then, as we have learnt from the Cochrane Review linked to above, it has “no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school”.

    As Andrew Gilbey recently commented, it makes you wonder why chiropractic needs to exist at all.

  • David

    “You haven’t answered my question. Are you seriously suggesting that the GMC should be a doctor-free organisation? Or, that dentists should be regulated by an organisation with no dentists involved?”

    I’m sorry if I wasn’t clear enough in what I said earlier (but make sure you read what I said about calling experts when required). But you still haven’t said why you think such a suggestion is ridiculous. Can you answer my question about which sections of the COP need a chiro to decide?

    Are you someone perhaps who thinks that MPs should decide on their own expenses because they’re really the only ones who can possibly know what a legitimate MP’s expense is? Would you agree we need a fully independent PCC? I’d really like to know your views on that.

  • David said: “I suspect you’re right in that you have been paying too much attention to the wrong websites.”

    Which wrong websites would that be? There are so many chiro websites out there making outlandish claims.

    “If you don’t care what I (or any of my chiropractic colleagues) think, then that suggests that your presence here is simply to heckle rather than to debate.”

    I’ve raised pertinent questions about how chiros should be regulated, so your remark about my “presence here is simply to heckle rather than to debate” is a bit wide of the mark.

  • @joemac
    I think David is referring to the American websites you referred to in your previous posting.
    Asking a pertinent question is very valuable, thank you. Eliciting responses is also. Engaging with the arguments laid out in the responses makes it a debate. Failing to do so, does indeed make a heckler.
    Regards
    Stefaan

  • Thanks for putting me right on the etiquette of commenting on Zeno’s blog, Stefaan.

    Although I’ve not been successful in eliciting responses so far, I’d still like to know what sections of the COP need a chiro to decide on?

  • @Joemac
    Glad to be of service
    It seems rather natural to have a chiropractor on panel of a chiropractic council. Primarily to offer an insight in the real-life challenges of a chiropractor to balance the reality as perceived by laymen. Clinical reality presents challenges and considerations which are not automatically considered by laymen. In itself I have no issue with laymen providing judgement over me, but that judgement needs to be balanced off against that provided by people who know what life is like for me. Thing is, if it does seem normal and natural to have a chiropractor on panel, then it is you who needs to justify doing something rather unnatural. So I ask from you: Why would you NOT want a chiropractor on panel?
    Stefaan

  • Stefaan said: “It seems rather natural to have a chiropractor on panel of a chiropractic council.”

    I’m not convinced that seeming natural is an adequate reason.

    “Primarily to offer an insight in the real-life challenges of a chiropractor to balance the reality as perceived by laymen. Clinical reality presents challenges and considerations which are not automatically considered by laymen. In itself I have no issue with laymen providing judgement over me, but that judgement needs to be balanced off against that provided by people who know what life is like for me. Thing is, if it does seem normal and natural to have a chiropractor on panel, then it is you who needs to justify doing something rather unnatural.”

    As I said way back, I have no problem with a chiro (or any other) expert being called to give advice on chiro, clinical reality, etc, but why should that person be a party to the decision about whether a chiro has breached the clearly laid out rules? Why should he/she have a vote on the decision? I don’t even have a problem with a chiro expert being consulted in every case, but it still boils down to a decision about whether a chiro has complied with the COP or has not and lay persons can make that decision, taking into account the expert opinion.

    “So I ask from you: Why would you NOT want a chiropractor on panel?”

    For very obvious reasons, Stefaan. Would you not agree that where a statutory regulator is concerned, justice must be done and must be seen to be done? I have little confidence in MPs deciding what MPs expenses are legitimate; I have little confidence in the PCC deciding whether their own members have breached their code, so why should I have confidence in chiros deciding whether their fellow chiros have breached their COP? Why not take it out the hands of chiros completely and make it independent? What’s to be feared from that independence?

    I think this bypasses my question: what sections of the COP can’t be decided on by anyone other than a chiro?

  • I think having one or a few chiropractors, balanced in numbers with lay-men is perfectly natural on a chiropractic council . If you don’t it’s up to you to go and change the rules if you feel so passionate about it and can rally enough people around it. It just seems non-sensical to me, but if you’re that passionate about it; good luck.
    Stefaan

  • Stefaan

    Why should it be evenly balanced and why should that be ‘natural’? Even now, the numbers aren’t evenly balanced, but skewed in favour of chiros. (That certainly leaves the perception of bias – whether it is actual or not – and that can’t be good for transparency.)

    Why do you think what I suggest is nonsensical?

    Perhaps David will have some answers.

  • @ Blue Wode

    Blue Wode wrote: “And which parts of the science I’ve presented to you do you think are ‘distorted’?”

    Plenty. Especially your habit of offering opinion as if it’s fact, and shoehorning out-of-context quotes and “evidence” into your posts to bolster your propaganda.

    David wrote: “The graph in your post simply relates to the fact that chiropractors perform much the most manipulation that is done.”

    I notice that you haven’t denied this and I use it as evidence of your habit as described above.

    Blue Wode wrote: “But why do they do it [manipultion] when there are effective, safer, cheaper and more convenient options available? To me, it smacks of large-scale malpractice.”

    It’s time we put this one to bed. There are no techniques that are shown to be more effective than the complete chiropractic package for the conditions that chiropractors spend the vast majority of their time treating. That is, neuromusculoskeletal disorders.

    The issue of safety has been massively overblown by Ernst et al, as has been discussed many times before. As we know, the risks of serious side-effects of chiropractic treatment are tiny and largely related to pre-disposed individuals. The stroke issue has been cynically exaggerated and as I have demonstrated, chiropractors have been wrongly accused of causing strokes.

    This is where you trot out your usual rubbish about up to 50% of patients suffering minor side-effects after treatment. However, we have already shown that this amounts to no more than the sort of mild, transient soreness that one might experience after a session in the gym and is to be expected when ANY treatment is being applied to an already sore condition.

    When it comes to cost, it’s intersting to look at the figures. Having negotiated contracts with the local Primary Care Trust, the managers tell me that the cost of a physiotherapy appointment on the NHS totals between £47 to £50, once one has factored in the provision of the facility, the staff, the practitioner etc. In my area the cost of a chiropractic appointment ranges between £30 and £35. So, chiropractic is not only effective, but also cost-effective and when available on the NHS, as suggested by NICE, free at the point of delivery.

    As part of your patter you regularly suggest that other treatments are more convenient, but I am uncertain what your evidence is. We have appointments available for patients between 8am and 8pm during the week and between 8am and 1pm on Saturdays. It is part of our policy that patients should be able to be seen within one working day because it is well known that early intervention is important. Are there any other, equally effective therapies available more conveniently?

    Blue Wode wrote: “The latest Cochrane review on spinal manipulative therapy for low-back pain claims the following:

    “Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low-back pain were similar. Radiation of pain, study quality, *profession of manipulator*, and use of manipulation alone or in combination with other therapies *did not affect these results*.”

    Like I said, the science is incomplete. Here is an extracrt from a study published in April 2010:

    Quote:
    “There are *no* systematic reviews comparing the efficacy of targeted versus non-targeted manual therapy and/or exercise.”
    http://www.biomedcentral.com/content/pdf/1741-7015-8-22.pdf

    Blue Wode wrote: “And those of well-respected, impartial scientists, Simon Singh and Professor Edzard Ernst…………..”

    You must have your tongue shoved pretty firmly in your cheek to keep a straight face when you put out this stuff. I can tell you that Prof Ernst is nothing like as well respected as you would like. He is increasingly being recognised as a slightly crazed figure who is obsessed with the denigration of CAM, but of course mostly chiropractic. This comes from those I have met who have worked with him, not from those for whom he is a thorn in the side. As for Simon Singh, he may be a scientist but his authority to comment on chiropractic comes only from his association with Ernst…………

    Blue Wode wrote: “David wrote: “As you well know, chiropractic is about a great deal more than manipulation…”

    And as you well know, anything other than a chiropractic ‘adjustment’ is not chiropractic. It’s physical therapy.”

    I love this! I know you’re just being mischievous but you know perfectly well that that comment is complete drivel.

    So, we’ve established that chiropractic is safe, effective, cost-effective and convenient.

    The last point is that patients like it. It’s what they choose to do for themselves and that is why they refer their friends and family to us.

    Have you ever seen a chiropractor? I suspect that you haven’t but I think you would do well to try it for yourself and if you would like a rcommendation on whom to consult then let me know.

  • @JoeMac
    Why do you say it is skewed in favour of chiropractors? Are you making assumptions that having chiropractors’ presence skewes in favour of chiropractors or are your concerns based on anything more than personal views?
    Would love to know.
    I don’t think your suggestion is in itself nonsensical. The assumptions I am assuming they are based on and the emotions I assume they are driven by, on the other hand do seem rather nonsensical to me: i.e. the assumption that chiropractors on the panel would skew the panel in favour of chiropractors.
    I don’t think many chiropractors would agree with you on that one…
    Stefaan

  • It is skewed because there are more chiros than lay members – this could give rise to the perception that it may be biased – remember what I said about being seen to be impartial? Surely this is not good for chiros or the public? If it appears that it may not be impartial, then the public will lose confidence in that regulator (cf the PCC).

    As for your assumption that my suggestion is based on emotion, you really need to re-read what I said. I put forward cogent arguments why there doesn’t need to be any chiros making these decisions, never mind a majority of them. Look at the IC. As Zeno says, they are there to look at the evidence they have tried (possibly not very hard) to gather evidence and decide whether it is sufficient to establish whether or not there is a case to answer. No decision is (or rather should) be made about guilt or innocence at this stage, so why does it need a chiro to make that decision? An allegation has been made – is there evidence to support that allegation?

    This is getting a bit like a broken record, but I’m getting no answers to it: what sections of the COP can only be decided by a chiro? I’ll re-state them because they seem to have disappeared onto a previous page of comments:

    A You must respect patients’ dignity, individuality and privacy
    B You must respect patients’ rights to be involved in decisions about their healthcare
    C You must justify public trust and confidence by being honest and trustworthy
    D You must provide a good standard of practice and care
    E You must protect patients and colleagues from risk of harm
    F You must cooperate with colleagues from your own and other professions

  • @ JoeMac

    I see that Stefaan has replied before I had a chance to and there’s not really much to add to what he’s said.

    You’ve asked about whether it’s necessary to have a chiropractor involved in some very specific matters but I think the important question is, what should the composition of the GCC be? I think it is nonsensical for there to be no chiropractors on the GCC but I believe it to be entirely appropriate for there also to be ley members on council in order to provide the necessary balance.

    Incidentally, I don’t think you’ve answered my question about whether you believe that the GMC and GDC should alos be devoid of doctors and dentists respectively.

  • David

    See my answer to Stefaan.

    I didn’t say it wasn’t “necessary to have a chiropractor involved in some very specific matters”. What I did say there was no need to have any chiros making the decision. I did say that an expert could be consulted as and when required.

    You keep stating that it is ‘nonsensical’ not to have chiros, but I’ve still to read any good arguments as to why you think so.

    Let me ask a slightly different question: why do you need lay members? What are they there for? You say they provide ‘necessary balance’, but balance to what?

    I’ve obviously not made it clear that I have not been convinced that any profession – particularly one involving health – should be regulated by its own members and I’ve given other examples where self regulation clearly has not worked.

    However, we’re talking about the GCC and chiros here and you guys still need to come up with arguments as to why chiros are needed to decide on whether their COP has or has not been breached.

  • @Joemac
    You misread my comment: I commented that I assumed your suggestions were based on nonsensical assumptions and driven by emotions. As are most human actions. Not, as you say that your suggestions are based on emotions. I suggest you re-read my comment… and follow your own suggestions.
    A: There are no aspects of the COP that can only be decided by a chiropractor. Chiropractors are just better placed to make certain comments on nuances and technical differentiations which take years to understand appreciate and contextualise. Which is why it is nonsensical to assume that General Councils of any healthcare profession (who all have such nuances which laymen often do not appreciate) would be “better” when more neutral or less biased in the absence of the profession they represent. The “bias” is integral part of the profession, which is insight it requires to make balanced judgement.
    Like I said, feel free to go and change it, but you will, I feel, fail to get the support as it is obvious that the neutrality you yearn for is misguided. What you are looking for is integrity. Unless of course you are saying that the GCC has compromised integrity in favour of chiropractors. I would however suggest you are very heavily mistaken. If anything it has been accused of being the biased against chiropractors…
    Stefaan

  • @ JoeMac

    As ever, Stefaan has made all the necessary points perfectly well and I need add nothing more.

    Please forgive me if I’ve missed it, but have you actually said whether you feel that ALL healthcare regulatory bodies should be devoid of the relevant professionals, or only the GCC?

  • Hi David
    thank you.
    You are a very handsome man.
    Stefaan

  • @ David

    ”you trot out your usual rubbish”

    Please refrain from making insults. It is not becoming of a healthcare professional.

    David wrote: “[BW]And which parts of the science I’ve presented to you do you think are ‘distorted’?” Plenty. Especially your habit of offering opinion as if it’s fact, and shoehorning out-of-context quotes and “evidence” into your posts to bolster your propaganda.”

    Please give examples.

    David wrote: ““The graph in your post simply relates to the fact that chiropractors perform much the most manipulation that is done.” I notice that you haven’t denied this and I use it as evidence of your habit as described above.”

    If you go back and read my response, you will see that I enquired why chiropractors perform *so much* manipulation when there are effective, safer, cheaper and more convenient options available. I then went on to comment that I thought it smacked of large-scale malpractice. With reference to Fig. 2 in the link I provided, I would venture that using manipulation judiciously (i.e. very rarely and only after having gained fully informed consent from the patient) would likely see the numbers of adverse events associated with chiropractic plummet.

    David wrote: “There are no techniques that are shown to be more effective than the complete chiropractic package for the conditions that chiropractors spend the vast majority of their time treating.”

    But you still cannot escape the fact that a responsible RISK/BENEFIT assessment for chiropractic spinal manipulation will show it to be largely unfavourable when there are other equally effective, cheaper, more convenient, and safer options available. Such an assessment would also include chiropractic spinal manipulation for back pain for the reason given in the quote below which is lifted from a critique of the recent NICE guidelines for low-back pain:

    Quote
    “…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.* 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.]
    http://tinyurl.com/y8dmwcs

    * Ref: Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35: 544–62.

    David wrote: “The issue of safety has been massively overblown by Ernst et al, as has been discussed many times before. As we know, the risks of serious side-effects of chiropractic treatment are tiny and largely related to pre-disposed individuals. The stroke issue has been cynically exaggerated and as I have demonstrated, chiropractors have been wrongly accused of causing strokes.”

    Having trained and worked as an MD, followed by being Head of the Department of Physical and Rehabilitation Medicine in the University of Vienna’s Medical Faculty, Professor Edzard Ernst is not only very familiar with physical therapies, he has also been trained in spinal manipulation and has applied it clinically. This sound scientific background can be seen in all his evaluations since he invariably applies the cautionary principle to each of his analyses in the interests of patient safety.

    Where is your cautious attitude, David?

    David wrote: “This is where you trot out your usual rubbish about up to 50% of patients suffering minor side-effects after treatment. However, we have already shown that this amounts to no more than the sort of mild, transient soreness that one might experience after a session in the gym and is to be expected when ANY treatment is being applied to an already sore condition.”

    I would refer you to my answer above where I link to Ernst’s comments on the recent NICE guidelines for low-back pain.

    David wrote: “When it comes to cost, it’s interesting to look at the figures. Having negotiated contracts with the local Primary Care Trust, the managers tell me that the cost of a physiotherapy appointment on the NHS totals between £47 to £50, once one has factored in the provision of the facility, the staff, the practitioner etc. In my area the cost of a chiropractic appointment ranges between £30 and £35. So, chiropractic is not only effective, but also cost-effective and when available on the NHS, as suggested by NICE, free at the point of delivery.”

    According to a 2006 systematic review the use of spinal manipulation represented an additional cost to conventional treatment:
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1697737/?tool=pubmed

    Also, I’d be interested to know what measures are in place to prevent NHS patients being ensnared by the chiropractic ‘bait and switch’ (http://www.dcscience.net/?p=1516 ), or being exploited by the recommendation of expensive, ongoing, unnecessary, and unproven ‘maintenance care’ treatments.

    David wrote: “As part of your patter you regularly suggest that other treatments are more convenient, but I am uncertain what your evidence is…Are there any other, equally effective therapies available more conveniently?”

    Doesn’t the most recent Cochrane Review of spinal manipulative therapy (SMT) for low back pain say that SMT has “no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school”? Wouldn’t analgesics and exercises be more convenient for a patient? As for spinal manipulation for neck pain, we already know that exercise is just as an effective option and it hasn’t been associated with significant risks (unlike neck manipulation).

    David wrote: “So, we’ve established that chiropractic is safe, effective, cost-effective and convenient.”

    No, we haven’t. We’ve established that chiropractic is as effective as some other therapies for back and neck pain, but that it is less safe, more costly, and less convenient.

    David wrote: “The last point is that patients like it. It’s what they choose to do for themselves and that is why they refer their friends and family to us.”

    The appeal to popularity argument (argumentum ad populum), does not make something so, and it remains apparent that chiropractic is increasingly struggling to find good evidence for its interventions beyond non-specific (placebo) effects. I suggest that you have a read through the late Barry Beyerstein’s classic essay, ‘Social and Judgmental Biases That Seem to Make Inert Treatments Work’. It is a thorough analysis of alternative medicine and common errors of reasoning:
    http://www.sram.org/0302/bias.html

    Indeed, a read of that essay would suggest that chiropractors are simply serving as an expensive distraction whilst their patients’ ailments run their natural courses. For example, a comparison of physical therapy, chiropractic manipulation, and the provision of an educational booklet for the treatment of patients with low back pain arrived at the following conclusion:

    Quote
    “…the McKenzie method of physical therapy and chiropractic manipulation had similar effects and costs, and patients receiving these treatments had only marginally better outcomes than those receiving the minimal intervention of an educational booklet. Whether the limited benefits of these treatments are worth the additional costs is open to question.”
    http://tinyurl.com/ya7hsfe

    Also, when you consider Edzard Ernst’s views on the BEAM trial (which estimated the effect of adding exercise classes, spinal manipulation delivered in NHS or private premises, or manipulation followed by exercise to “best care” in general practice for patients consulting with back pain) they support the suggestion that time and reassurance play the greatest role in a patient’s recovery:
    http://www.bmj.com/cgi/eletters/bmj.38282.669225.AEv1#88126

    This recent review in one of your trade publications also makes interesting reading:

    Why do ineffective treatments seem helpful? A brief review
    http://www.chiroandosteo.com/content/17/1/10

    David wrote: “Have you ever seen a chiropractor? I suspect that you haven’t but I think you would do well to try it for yourself and if you would like a recommendation on whom to consult then let me know.”

    It is not necessary for anybody to try chiropractic. All that is required is to read up on what the science tells us about it – from a reliable resource.

  • Stefaan said:

    “There are no aspects of the COP that can only be decided by a chiropractor.”

    I’m glad we agree on that.

    “Chiropractors are just better placed to make certain comments on nuances and technical differentiations which take years to understand appreciate and contextualise.”

    And why can’t a chiro be consulted as an expert on this, allow him/her to consider whatever nuances and technical differentiations he wants and then give his/her considered opinion to whatever committee? Does that chiro expert, after giving his advice then need to vote with or against other committee members? (I assume these things are put to the vote after the deliberations?) I would certainly expect the committee to accept the opinion of the chiro and balance it with counter arguments and evidence given the complainee. (I would also expect the expert to be an expert in the same way other tribunals/courts use experts – I assume that’s already what they do?) Think about juries: they don’t have to be experts in criminal law or whatever crime the accused is charged with to be able to make a decision that could send him to prison. The courts/tribunal will call expert testimony and it is for the court to decide the merit taking all the evidence into account. What makes chiros different?

    “Which is why it is nonsensical…”

    No. That does not make it nonsensical (but it does make it non-independent). That may be the status quo, but I’ve still not seen any arguments against calling expert witnesses and leaving the final decision to the committee, taking all the evidence into account.

    “…to assume that General Councils of any healthcare profession (who all have such nuances which laymen often do not appreciate) would be “better” when more neutral or less biased in the absence of the profession they represent. The “bias” is integral part of the profession, which is insight it requires to make balanced judgement.”

    So why are there any lay members (I asked that earlier). If they may be nuances, etc that a lay person cannot possibly understand, why aren’t the committees all chiros? Surely you’re saying that a mere layman couldn’t possibly deliberate on the actions of a chiro – then why do they? Or are the lay members of the committees not lay members at all?

    “Like I said, feel free to go and change it, but you will, I feel, fail to get the support as it is obvious that the neutrality you yearn for is misguided.”

    “Neutrality is misguided”? Why is it misguided to expect decisions by a statutory body to be neutral? Surely that’s the only way public confidence can be won and maintained? BTW, I didn’t say I was going to change it, it just seemed somewhat odd and worrying that decisions about chiros are made by fellow chiros. However, maybe I’ll write to my MP.

    “What you are looking for is integrity. Unless of course you are saying that the GCC has compromised integrity in favour of chiropractors.”

    I’ve no idea if the GCC is acting with integrity or not. And that’s the heart of the matter – it is not transparent to the public. Perhaps Zeno has been given full details of exactly how the IC came to the decisions it did, but given the lack of these details in his posts, and since there appears to be none of these IC decisions on their website, it seems unlikely. Do you know?

    “I would however suggest you are very heavily mistaken.”

    Why is it mistaken to expect a statutory regulatory body to be transparent and independent? I’m sure I asked this earlier: isn’t that what the public should expect and deserve?

    “If anything it has been accused of being the biased against chiropractors…”

    What accusations of bias against chiros? And what’s the evidence to back that up?

  • Blue Wode wrote: “If you go back and read my response, you will see that I enquired why chiropractors perform *so much* manipulation when there are effective, safer, cheaper and more convenient options available. I then went on to comment that I thought it smacked of large-scale malpractice. With reference to Fig. 2 in the link I provided, I would venture that using manipulation judiciously (i.e. very rarely and only after having gained fully informed consent from the patient) would likely see the numbers of adverse events associated with chiropractic plummet.”

    I’ve re-read your post and I cannot see where you said that you were enquiring about why chiropractors do “so much manipulation”. When you referenced “Fig 2″ in your earlier post, the point you were trying to make was that chiropractic manipulation of the neck is more dangerous than physiotherpy manipulation. However, that is not what the graph shows and the suggestion you make is a misrepresentation of the “evidence”. Whether this is mistaken or deliberate is open to speculation.

    Blue Wode wrote: “I would venture that using manipulation judiciously (i.e. very rarely and only after having gained fully informed consent from the patient) would likely see the numbers of adverse events associated with chiropractic plummet.”

    So, finally an admission that there is a place for manipulation in the management of neck disorders. Of course, no treatment is given to the patient before fully informed consent is obtained.

    Blue Wode wrote: “Where is your cautious attitude, David?”

    What evidence do you have that MY attitude is any less cautious than is appropriate?

    Blue Wode wrote: “It is not necessary for anybody to try chiropractic. All that is required is to read up on what the science tells us about it – from a reliable resource.”

    As we’ve said, the science is incomplete and that which has been published is not definitive. When it comes to reliable resources, I’ll take it that you would automatically discount any chiropractors from that. Sadly, as I have illustrated above, there is a great deal of misinformation about chiropractic from those who claim to be impartial. I haven’t bothered to trawl through your website, but there remains the real question about accuracy, let alone objectivity, in the material you direct people to.

    Blue Wode wrote: “@ David
    ”you trot out your usual rubbish”
    Please refrain from making insults. It is not becoming of a healthcare professional.”

    Making a statement of fact shouldn’t be misinterpreted as making an insult.

    While we’re at it, I’m still waiting for a response to this exchange on 30th June 2010 on this blog:
    Blue Wode wrote: “It is not in the emotional or financial interests of CAM practitioners (chiropractors included) to inform the public about the lack of evidence for their various interventions. As a result, it is often left to members of the public themselves to learn how to make informed choices if they are to avoid inappropriate and costly treatments. As I cannot abide dishonesty, I am more than willing to help them with that.”

    As I noted at the time:
    “That’s a straight-forward accusation of dishonesty and a strong suggestion that chiropractors’ sole purpose in practice is to relieve patients of thier money. I hope you’ve got the evidence to back that up.”

  • @Joemac
    Laymen are there to provide the public’s views and interpretation of the professional’s actions and intentions. Because there are two parties involved in the clinical encounter, it does seem a good and sensible idea to involve both parties in the process. Certain things which seem true and obvious to the clinician, may not seem so to teh patient and vice-versa. As is very well documented; the primary source of complaints is poor communication and interaction. Councils represent the parties involved. I understand the sentiment of your proposal and think it noble but based in an inaccurate understanding of the clinical encounter. To assume that clinical interactions are power-neutral is erroneous and reeks of “partnership-healthcare”. The level of expertise involved in spinal care and rehabilitation is so high and the complexities so intricate that such power-neutral partnership healthcare would be inappropriate. Chiropractors play the role of both primary and secondary care providers. For that situation it would be inappropriate for laymen to judge and evaluate the situation without expert opinion of a representative chiropractor (and this by no means implies support to the chiropractor complained about cf; have a look at http://www.chiropracticlive.com if you would like some references about perceived GCC bias against chiropractors). If a chiropractor should be brought in as expert as you suggest, then what is the difference to letting the chiropractor sit on the panel? I am just trying to be practical here, but as I already stated, I am not precious about it.
    You make reference with quotes in your last post. Please reread the context those quotes were in. The answers to your questions lie in that they weren’t stated as you interpreted. Sorry for maybe not being very clear.
    @BlueWode
    Thing is: I don’t think you understand clincial reality and a lot of your comments are misguided from a clinical standpoint and not great from a scientific standpoint (but better) either.
    It’s OK, we can’t all be doctors. All the best, just one piece of advice EBM is not RCT medicine. You really need to rethink and have a chat with experienced clincians before you do any more damage ot your reputation.
    Stefaan

  • @ David
    Despite your protests to the contrary, chiropractic neck manipulation *is* more dangerous than manipulation by physical therapists:

    Quote
    “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…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…
    While physical therapists, physiatrists, osteopaths, and orthopedists sometimes manipulate the neck for a carefully selected musculoskeletal problem, chiropractors who are guided by the ACC’s subluxation paradigm may routinely manipulate the neck, thus subjecting the patient to unnecessary risk.[16] 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]
    “…until chiropractors are uniformly specialized in treatment methods and scope of practice, and chiropractic associations openly denounce the nonsense that permeates the profession, chiropractors cannot be recommended across the board. Hit-and-miss reliability among chiropractors makes it necessary for physicians and other health professionals to stay on the safe side and recommend physical therapists rather than chiropractors…
    Since physical therapists use mobilization more often than manipulation, and use much less neck manipulation than chiropractors who routinely manipulate the spine, there may be less injury and a lower incidence of stroke associated with physical therapy than with chiropractic treatment. For example, a review of 177 cases of injury caused by manipulation of the cervical spine (MCS), reported in 116 articles published between 1925 and 1997, revealed that “Physical therapists were involved in less than 2% of the cases, and no deaths have been attributed to MCS provided by physical therapists.”[18]”

    http://www.sciencebasedmedicine.org/?p=1037

    David wrote: “Blue Wode wrote: ‘I would venture that using manipulation judiciously (i.e. very rarely and only after having gained fully informed consent from the patient) would likely see the numbers of adverse events associated with chiropractic plummet’. So, finally an admission that there is a place for manipulation in the management of neck disorders. Of course, no treatment is given to the patient before fully informed consent is obtained.”

    Yes, with major caveats, there may, on rare occasions, be a place for neck manipulation (see my quote from retired, science-based, chiropractor, Samuel Homola, above). However, you are not correct in saying that “no treatment is given to the patient before fully informed consent is obtained”. It is evident that many chiropractors are failing to tell patients not only of the lack of scientific evidence for ‘chiropractic’, but also of the risks involved with it:

    Consent: its practices and implications in United Kingdom and United States chiropractic practice
    CONCLUSION: Results from this survey suggest a patient’s autonomy and right to self-determination may be compromised when seeking chiropractic care. Difficulties and omissions in the implementation of valid consent processes appear common, particularly in relation to risk.
    http://tinyurl.com/6ajn5d

    Consent or submission? The practice of consent within UK chiropractic
    CONCLUSION: Results suggest that valid consent procedures are either poorly understood or selectively implemented by UK chiropractors.
    http://tinyurl.com/559ued

    Indeed, it you watch this CTV clip (3 mins) you will see tetraplegic chiropractic victim, Sandra Nette, confirm that she wasn’t told about the potential risks involved with her chiropractic treatment:
    http://watch.ctv.ca/news/latest/class-action-lawsuit/#clip59878

    David wrote: “What evidence do you have that MY attitude is any less cautious than is appropriate?”

    Please re-read my rebuttals to your comments.

    David wrote: “Blue Wode wrote: ‘It is not necessary for anybody to try chiropractic. All that is required is to read up on what the science tells us about it – from a reliable resource.’ As we’ve said, the science is incomplete and that which has been published is not definitive. When it comes to reliable resources, I’ll take it that you would automatically discount any chiropractors from that. Sadly, as I have illustrated above, there is a great deal of misinformation about chiropractic from those who claim to be impartial. I haven’t bothered to trawl through your website, but there remains the real question about accuracy, let alone objectivity, in the material you direct people to.”

    If the science is incomplete, and there are serious risks associated with a treatment, then, as a matter of ethics, practitioners should be erring on the side of caution and not proceeding *as if* the science was already there. With regard to chiropractic, I would disagree with you about the science for it being incomplete. Just look at the recent internet-wide destruction of the British Chiropractic Association’s “plethora” of evidence for treating childhood ailments:
    http://www.bmj.com/cgi/content/full/339/jul08_4/b2783

    I would also refer you to what British scientists, Simon Singh and Edzard Ernst, propose in their book ‘Trick or Treatment? Alternative Medicine on Trial’ (p.285), that all chiropractors be compelled by law to disclose to their patients 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.”

    David wrote: “Blue Wode wrote: ‘@ David ”you trot out your usual rubbish” Please refrain from making insults. It is not becoming of a healthcare professional.’ Making a statement of fact shouldn’t be misinterpreted as making an insult.”

    Let’s get serious. Nearly all my comments are referenced by good evidence or valid reasons for concern, whereas most of yours are not.

    David wrote: “While we’re at it, I’m still waiting for a response to this exchange on 30th June 2010 on this blog: Blue Wode wrote: ‘It is not in the emotional or financial interests of CAM practitioners (chiropractors included) to inform the public about the lack of evidence for their various interventions. As a result, it is often left to members of the public themselves to learn how to make informed choices if they are to avoid inappropriate and costly treatments. As I cannot abide dishonesty, I am more than willing to help them with that.’ As I noted at the time: “That’s a straight-forward accusation of dishonesty and a strong suggestion that chiropractors’ sole purpose in practice is to relieve patients of thier money. I hope you’ve got the evidence to back that up.”

    No, it is not, as you claim, a “straight-forward accusation of dishonesty”. If you re-read what I wrote, you will see that I also included the *emotional interests* of chiropractors. In no way can that be viewed as a blanket implication that they are only in it for the money.

  • @ Blue Wode

    Blue Wode wrote: “Let’s get serious. Nearly all my comments are referenced by good evidence or valid reasons for concern, whereas most of yours are not.”

    I’m absolutely dead serious about this and I’m not messing around here. The fact is that the references you provide are often out of context, often not accurately described and often not even relevant to chiropractic as it is practised by the vast majority of chiropractors in the UK. I would much rather not be spending my time doing this, but there is so much misinformation in your posts that they have to be countered.

    Blue Wode wrote: “Despite your protests to the contrary, chiropractic neck manipulation *is* more dangerous than manipulation by physical therapists:”

    That is simply not true. Your quote only claims that neck manipulation is more *problematic* among chiropractors because manipulation is performed more often by chiropractors than anyone else. The (mistaken) suggestion is that neck manipulation is dangerous, whoever it’s performed by. YOUR assertion is that manipulation by chiropractors is more dangerous than that performed by physiotherapists and there is ABSOLUTELY no evidence to support that.

    You can’t have it both ways. On the one hand you are claiming that neck manipulation is dangerous, and then on the other hand you are claiming that it is an appropriate treatment but somehow dangerous when performed by chiropractors. Again, you have ABSOLUTELY NO EVIDENCE to support that and the truth is that chiropractors are the professionals best placed to perform all manipulation, not just of the spine.

    Question: As you (someone who is, as far as we know, not qualified or trained in any form of healthcare), have conceded that there is a place for manipulation of the neck, what evidence do you have that anyone else is better qualified to administer than manipulation than a chiropractor?

    Blue Wode wrote: “Few chiropractors specialize in the care of back pain and other musculoskeletal problems”

    One of the big problems here is that you are desperately ill-informed about present-day chiropractic in the UK. Specializing in the care of back pain and other musculoskeletal problem is PRESCISELY what chiropractors do.

    Blue Wode wrote: “Chiropractors who [.....] specialize in the care of back pain will use manipulation more appropriately.”

    So, as we’ve established, chiropractors use of manipulation is entirely appropriate.

    Blue Wode wrote: “It is not in the emotional or financial interests of CAM practitioners (chiropractors included) to inform the public about the lack of evidence for their various interventions. As a result, it is often left to members of the public themselves to learn how to make informed choices if they are to avoid inappropriate and costly treatments. As I cannot abide dishonesty, I am more than willing to help them with that.”

    Despite your protestations, that IS a very clear and straight-forward accusation of dishonesty and one that you cannot back up. Your argument that you have not accused chiropractors of being in it only for the money because you have included their “emotional interests” is quite absurd.

    Am I to understand that you are absolving yourself of making this insult by asserting that chiropractors are satisfying their own emotional needs when treating patients?

    The worrying thing about your attitude to chiropractic is that I’m starting to think you actually believe the stuff you say. The truth, and believe me it is the truth, is that the vision of chiropractic you portray is far, far removed from the reality. However, it seems to me that you don’t want to believe that. You don’t want to believe that chiropractors specialise in the treatment of musculoskeletal disorders and take the safety of what they do very seriously. That it is chiropractors who are doing the big studies to establish the risks and benefits of what they do. That chiropractors are most interested in developing the science and their own skills in order to be able to better help their patients.

    Your interests seem to lie not in improving how musculoskeletal healthcare is practiced, but only in the demise of chiropractic. That’s called prejudice.

  • @David

    Blue Wode may have said that:

    “It is not in the emotional or financial interests of CAM practitioners (chiropractors included) to inform the public about the lack of evidence for their various interventions. As a result, it is often left to members of the public themselves to learn how to make informed choices if they are to avoid inappropriate and costly treatments. As I cannot abide dishonesty, I am more than willing to help them with that.”

    You may actually be right that Blue Wode makes an “…accusation of dishonesty…), but in assuming that he/she does make an accusation of dishonesty, strictly speaking, I think you are commit the logical fallacy, non-sequiter. That, is, Blue Wode may believe that “It is not in the emotional or financial interests of CAM practitioners (chiropractors included) to inform the public about the lack of evidence for their various interventions. As a result, it is often left to members of the public themselves to learn how to make informed choices if they are to avoid inappropriate and costly treatments”. But it doesn’t logically follow that his/her hatred of dishonesty means he is implying that chiropractors are dishonest!

    @David

    Where you say that, “chiropractors are most interested in developing the science and their own skills in order to be able to better help their patients.”, do you think chiropractors are able to answer these sorts of questions? That is, do you think they have an adequate understanding of research design? Some of the (positive) chiropractic research I’ve read suggests the answer is not exactly clear.

    Also, what you say implies that chiropractors seem to be seeking to find evidence to support their beliefs in what they do, rather than put what they do to the test. For me, and I believe quite a few others, the idea that cracking spines is going to do much other than, well, make a popping sound, is a bit of a stretch of the imagination; that said, I’m open to the fact that it is possible. In the same way that I’m open to the fact that ghosts may exist (my understanding of science suggests they do not). However, to be convinced, I’d personally need to see some bloody good studies. I’d also want to see every chiropractic study registered first, so that we don’t just get to read the spurious positive findings whilst the negative ones are left to rot in the filing cabinet.

  • @ David
    it does seem rather clear to me that Blue Wode is labouring under the impression that a profession practiced in one part of the world must be representative of that same profession as practiced elsewhere. I would suggest that by means of on-topic example physiotherapy in Scandinavian countries and in the UK are very different. It is also rather clear to me that BW assumes that information as found on the internet is representative of reality in a manner not dissimilar to David Gilbey assuming that “two and a half men” is.
    If what Blue Wode would like to see is full disclosure of the risks associated to upper cervical manipulation as he perceives it, I would suggest that he opens his eyes and notes that this already happens in the vast majority of chiropractic offices in the UK. I feel he is labouring under the impression that chiropractors are scared of doing so (qeue BW internet reference to chiropractor saying “if I did that they would all walk out”-@BW:one person feeling this way is not representative of the conduct of a profession on another continent). Chiropractors in the UK act responibly in this regard and err on the side of caution, as there is nothing to be lost in doing so. (Qeue BW and DG’s outdated and doubtful “survey”).
    The benefits of spinal manipulation have as of yet not been well researched as they have been researched in isolation. As such not representative of the chiropractic treatment method. The fact that the outcomes of research in the current design are frequently moderate to high in research design as it stands, is not only surprising but looks very encouraging when it is taken into account that there are other factors being taken into account by chiropractors (gait dysfunction, occlusion dysfunction and exercise to name but a few). Polycausation of back pain and other related syndromes is clearly challenging to BW and DG (not to mention many other so-called skeptics) as evidenced by their mono-causal evaluation of research.
    David Gilbey’s understanding of “spine popping” only further casts light on the acute lack of knowledge held by some in regards to the neurophysiological responses to high velocity, low amplitude capsular stretches associated to cavitation. I think it is in vain that we try to elucidate this matter to them, dear David as even after many mentions of these and many other obvious clinical facts, the same inadequate references are trotted out.
    If what they want is someone who manipulates spinal joints for the relief of back pain, then they are looking at the wrong profession. Certain people out there are already doing that, and the results are relatively poor. Chiropractic management is the next level up from this, for those patients where causation is either more complex or requiring a greater input and aims to establish causation, then rectify it. Where causation is purely spinal, then they should have improved with seeing a skilled and proactive physiotherapist, physiatrist or other, where it is not they may need to see other people too (podiatrists, dieticians, cognitive behavioural therapists, dentists) but this can only be actioned once causation has been established. Chiropractors are very good at this. I am certain that there would be other people who are good at this, but it is after all within the chiropractic philosophical paradigm to establishing the root cause, whether or not spinal and adjusting the cause either by the chiropractor where appropriate or by other technician where necessary and financially sensible. In consequence we do occasionally see people who could have improved from good hands-on physiotherapy but chose to come and see us due to being highly recommended, but by and large we see those who haven’t improved and are achieving great results with this mindful approach.
    In consequence, Chiropractors seem to be carving themselves an interesting niche rooted in their excellent results and broadened scope of enquiery. Thankfully for our profession, there aren’t that many people who are good at it but unfortunately it is a complex matter requiring high levels of expertise.
    Which is why the comments often made here are regularly missing the point by a wide margin. This too is unfortunate. As there is a great debate to be had, as long as the parties involved are actually willing to look at the realities and are looking at improving matters rather than further their prejudice.
    Stefaan
    This is only the beginning

    ps David Gilbey: clinical reality is NOT research reality. Clinicans are rarely particularly good at research methodology in ANY healthcare field.

  • @ Andrew Gilbey

    “But it doesn’t logically follow that his/her hatred of dishonesty means he is implying that chiropractors are dishonest!”

    The matter could be tidied up very easily if Blue Wode were to make it clear if he believes that chiropractors are being dishonest or not. If, as it appears, he is making an accusation of dishonesty, it would be honourable to forward the evidence.

    Andrew Bilbey wrote: “..what you say implies that chiropractors seem to be seeking to find evidence to support their beliefs in what they do, rather than put what they do to the test”

    No, it doesn’t imply that at all. What I said was exactly what I meant; chiropractors interests are in improving the knowledge and science base for neuromusculoskeletal care.

    As it happens, you are correct in saying that chiropractors are seeking answers to explain the effects that they see from their treatment, and properly so. The cry from the sceptics is always: “Where’s the evidence?” Are you suggesting that we shouldn’t be seeking the evidence?

    Andrew Gilbey wrote: “…..do you think chiropractors are able to answer these sorts of questions? That is, do you think they have an adequate understanding of research design? Some of the (positive) chiropractic research I’ve read suggests the answer is not exactly clear.”

    Perfectly able. The largest and most recent prospective study looking at the safety of neck manipulation was conducted by a chiropractor and published in Spine in 2007. The results show that in 50,000 neck manipulations, no serious adverse effects occurred. http://www.ncbi.nlm.nih.gov/pubmed/17906581

    This is when Blue Wode trots out his usual rebuttal of the study by Ernst. However, his “criticsims” amount to nothing more or less than an allegation that the chiropractors involved will have concealed any adverse events, and that the study authors will have exerted bias. Neither is true of course and he therefore has no evidence to support the allegations, but his desire is only to raise doubt rather than a quest for the truth.

  • @David
    Do you know something David, I have been reading their non-sensical rhetoric for so long now that I have come to accept that there might be greater risk than there actually is. I have come to accept that Ernst may have a valid point and that it is my responsability to make out there is a greater risk than there actually is (something I will probably keep on doing as it makes no difference whatsoever to patient acceptance of treatment) whereas in fact in the cold light of day, Ernst only has his opinions and accusations,… as is so often the case accusing others of the crime he perpetrates himself.
    Kind regards,
    Stefaan

  • @ Stefaan

    Thank you for your considered and measured posts. I’m afraid that the anger I feel at the misinformation and injustice that is being attempted gets the better of me sometimes.

  • @David,
    no, thank YOU for spending this much time and effort writing to post and counter these ridiculous comments. If at least they did the favour of building a decent argument, it wouldn’t seem like such a strain and we could all learn something, but you know as well as I do that as soon as it is countered with good argument they’lll just go to another blog or another post and put up the same discussion as if they have not taken in any of the concessions they made previously.
    It’s fun too though…
    Stefaan

  • David wrote @ Andrew Gilbey: “As it happens, you are correct in saying that chiropractors are seeking answers to explain the effects that they see from their treatment, and properly so.”

    Considering that a lot of the evidence/answers are already in, don’t you think that there’s a strong chance that chiropractors are misinterpreting the effects they see from their treatment? I think it would be time well spent if you were to have a slow read through ‘Social and Judgmental Biases That Make Inert Treatments Seem to Work’ by the late Barry Beyerstein:
    http://www.sram.org/0302/bias.html

    David wrote @ Andrew Gilbey: “The largest and most recent prospective study looking at the safety of neck manipulation was conducted by a chiropractor and published in Spine in 2007. The results show that in 50,000 neck manipulations, no serious adverse effects occurred. This is when Blue Wode trots out his usual rebuttal of the study by Ernst.”

    And here it is: http://tinyurl.com/38cptsp

    I would also refer you to the recent critique of the Cassidy et al study:

    “The most benign interpretation of the totality of the evidence is [therefore] as follows. There is an association between chiropractic and vascular accidents which not even the most ardent proponents of this treatment can deny. The mechanisms that might be involved are entirely plausible. Yet the nature of this association (causal or coincidental) remains uncertain. The cautionary principle, demands that until reliable evidence emerges, we must err of the safe side. Considering also that the evidence for any benefit form chiropractic neck manipulations is weak or absent, I see little reason to advise in favour of upper spinal manipulation.”

    Ernst, E. Vascular accidents after chiropractic spinal manipulation: Myth or reality?, Perfusion 2010; 23:73-74
    http://tinyurl.com/37ejj22

    Stefaan Vossen wrote @ David: “…it does seem rather clear to me that Blue Wode is labouring under the impression that a profession practiced in one part of the world must be representative of that same profession as practiced elsewhere.”

    IMO, the lack of standardisation in chiropractic is one of its major problems – and I would guess that most patients, unfortunately, are unaware that it exists.

    Stefaan Vossen wrote @ David: “If what Blue Wode would like to see is full disclosure of the risks associated to upper cervical manipulation as he perceives it, I would suggest that he opens his eyes and notes that this already happens in the vast majority of chiropractic offices in the UK.”

    Then I would be interested in reading more up-to-date surveys than the two I have already cited which suggest otherwise:
    http://tinyurl.com/6ajn5d and http://tinyurl.com/559ued

    Stefaan Vossen wrote @ David: “I feel he is labouring under the impression that chiropractors are scared of doing so”

    If chiropractors are *not* scared of disclosing the full risks of treatment, what would be reasons for so many of them failing to do so, as evidenced by the conclusions of the surveys cite immediately above?

    Stefaan Vossen wrote @ David: “The benefits of spinal manipulation have as of yet not been well researched as they have been researched in isolation. As such not representative of the chiropractic treatment method.”

    I wonder how near the mark the following link to a post on the difference between The Scientific Method of Investigation and the Chiropractic Method of Investigation is?
    http://tinyurl.com/394oyk5

    BTW, it’s worth noting that it was a chiropractor who made, and agreed with, the information contained in that link.

    David wrote: “The fact is that the references you provide are *often* out of context, *often* not accurately described and *often* not even relevant to chiropractic as it is practised by the vast majority of chiropractors in the UK.”

    Often? Evidence please.

    David wrote: “YOUR assertion is that manipulation by chiropractors is more dangerous than that performed by physiotherapists and there is ABSOLUTELY no evidence to support that.”

    I stand by that assertion. To clarify, due to the *inappropriate frequency* with which manipulation is used by chiropractors (particularly neck manipulation), it is more dangerous than that performed by physiotherapists and others.

    David wrote: “…the truth is that chiropractors are the professionals best placed to perform all manipulation, not just of the spine.”

    Evidence please – including details of what measures are in place to prevent patients being ensnared by the chiropractic ‘bait and switch’:
    http://www.dcscience.net/?p=1516

    David asked: “As you (someone who is, as far as we know, not qualified or trained in any form of healthcare), have conceded that there is a place for manipulation of the neck, what evidence do you have that anyone else is better qualified to administer than manipulation than a chiropractor?”

    Please re-read Samuel Homola’s article which I cited at the end of an earlier quote. For your convenience, here is the link to it:
    http://www.sciencebasedmedicine.org/?p=1037

    David wrote: “Blue Wode wrote: “Few chiropractors specialize in the care of back pain and other musculoskeletal problems” One of the big problems here is that you are desperately ill-informed about present-day chiropractic in the UK. Specializing in the care of back pain and other musculoskeletal problem is PRESCISELY what chiropractors do.”

    Prescisely? Please provide an update on this 2007 survey:
    http://tinyurl.com/599vfs
    Ref. Aranka Pollentier and Jennifer M. Langworthy, The scope of chiropractic practice: A survey of chiropractors in the UK. Clinical Chiropractic, Volume 10, Issue 3, Pages 147-155. September 2007.

    Just to remind you, it revealed that…

    …76% of UK chiropractors deemed traditional chiropractic beliefs (chiropractic philosophy) to be important, and a figure of 63% was given for chiropractors who considered the fictitious ‘subluxation’ lesion to be central to chiropractic intervention. Interestingly, it also revealed that the responding chiropractors considered asthma (64%), gastro-intestinal complaints (61%) and pre-menstrual syndrome (PMS) (70%), as conditions that could benefit from chiropractic management (although opinions on the treatment of osteoporosis (43%), obesity (26%), hypertension (42%) and infertility (30%) were less conclusive). As for childhood musculoskeletal and muscular conditions, infantile colic, otitis media and asthma, they were perceived to benefit from chiropractic intervention by more than 50% of the respondents.

    David wrote: “Blue Wode wrote: “Chiropractors who [.....] specialize in the care of back pain will use manipulation more appropriately.” So, as we’ve established, chiropractors use of manipulation is entirely appropriate.”

    Please don’t twist things. A small number of chiropractors *might limit* their practice to the appropriate use of manipulation, but we don’t know how many, or who they are.

    David wrote: “Your argument that you have not accused chiropractors of being in it only for the money because you have included their “emotional interests” is quite absurd. Am I to understand that you are absolving yourself of making this insult by asserting that chiropractors are satisfying their own emotional needs when treating patients?”

    Yes, in part, but there will also be chiropractors who have realised too late that they are part of a dubious area of healthcare. Sadly, because many of them will have mortgages and families to support, they will be trapped into remaining part of it. (Such stories can be read with great regularity on the skeptical chiropractic discussion forum, Chirotalk.) Of course, there will be some chiropractors who view chiropractic as a means of scamming as much money as possible out of an unwitting public by using scare tactics and other marketing ploys designed (often by practice building outfits) to deliberately mislead.

    David wrote: “The worrying thing about your attitude to chiropractic is that I’m starting to think you actually believe the stuff you say.”

    It’s not a case of what I believe. I follow what the scientific evidence tells me.

    David wrote: “Your interests seem to lie not in improving how musculoskeletal healthcare is practiced, but only in the demise of chiropractic. That’s called prejudice.”

    As I have already stated, my interests lie in helping to ensure that the general public is given factual and accurate information about chiropractic (and other alternative therapies) in order for them to be able to make truly informed choices about their healthcare.

  • @David,

    You wrote about Blue Wode, “Your interests seem to lie not in improving how musculoskeletal healthcare is practiced, but only in the demise of chiropractic. That’s called prejudice”

    Surely, it’s only prejudice if it is without grounds. I think the majority of skeptics actually have grounds to query the existence of chiropractic; for example, quality evidence suggests it isn’t very effective, proper EBM medicine is already practiced, it may do harm, a good many chiropractors make ridiculously misleading claims, the scientific rationale for spinal manipulation is not very convincing, the risible idea of vertebral subluxations, etc.

  • @BW and David Gilbey
    good comments when viewd from your perspective. One thing which you are missing is the recognition of the asumption that your positioning is the right one.
    As chiropractors, in the UK, we are dealing with a market which is not being serviced by anyone. Bearing in mind that it is almost a requisite for people to have tried conventional strategies prior to visiting us, it is crucial for you to appreciate that our viewpoint is developed from a lack of choice, rather than malice or economically/emotionally driven bias. It is driven by an appreciation for the fact that the people we see have run out of options and the price for them to pay is pain, disability and loss of earnings amongst others.
    In this context you appear to fail to recognise the clinical reality of the situation: evaluation of lack of evidence versus the price of doing nothing. As it stands the successrates are very high, or at least seem to be in the eyes of the patients, and they, after all is said and done are the ones happy to pay for our services, and happy to recommend us to others.
    I frankly believe your beef is with something else, and I suspect it has more to do with a distrust of the integrity of clinicians who are put into this position of implied trust (as opposed to trust granted through evidence). I understand that, power and corruption are intimate bedfellows, and the fear or concern is not displaced. But that is why reputations are built slowly and destroyed rapidly, something which most of us are crucially aware of and the economical reality to this is the most ardent professional regulator.
    Stefaan

  • Blue Wode wrote: “Please don’t twist things.”

    That’s a bit rich coming from you.

    Blue Wode wrote: “Considering that a lot of the evidence/answers are already in, don’t you think that there’s a strong chance that chiropractors are misinterpreting the effects they see from their treatment?”

    The science is ony just beginning. The effects on neural efferent output by altering the afferent input with targeted alteration of joint mechanorecptors are only just being explored.

    Blue Wode wrote:”Please provide an update on this 2007 survey:
    http://tinyurl.com/599vfs….
    Just to remind you, it revealed that…
    …76% of UK chiropractors deemed traditional chiropractic beliefs (chiropractic philosophy) to be important, and a figure of 63% was given for chiropractors who considered the fictitious ‘subluxation’ lesion to be central to chiropractic intervention. Interestingly, it also revealed that the responding chiropractors considered asthma (64%), gastro-intestinal complaints (61%) and pre-menstrual syndrome (PMS) (70%), as conditions that could benefit from chiropractic management (although opinions on the treatment of osteoporosis (43%), obesity (26%), hypertension (42%) and infertility (30%) were less conclusive). As for childhood musculoskeletal and muscular conditions, infantile colic, otitis media and asthma, they were perceived to benefit from chiropractic intervention by more than 50% of the respondents.”

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

    Blue Wode wrote:
    “David wrote: “YOUR assertion is that manipulation by chiropractors is more dangerous than that performed by physiotherapists and there is ABSOLUTELY no evidence to support that.”
    I stand by that assertion. To clarify, due to the *inappropriate frequency* with which manipulation is used by chiropractors (particularly neck manipulation), it is more dangerous than that performed by physiotherapists and others.”

    You might stand by that assertion, but you still haven’t produced any evidence to support your allegation that chiropractic manipulation is any less safe than anyone else’s and I’m afraid your “clarification” doesn’t wash. Given that you have conceded (even though, as far as we are aware you have no qualifications with which to make any clinical judgement), that there is a place for neck manipulation, you now need to supply the evidence that that manipulation is any less safe when delivered by a chiropractor. The frequency is not the issue here.

    Blue Wode wrote: “It’s not a case of what I believe. I follow what the scientific evidence tells me.”

    We’ve got two major problems here. 1) The science is incomplete but that which is available shows chiropractic to be safe, effective, cost-effective, convenient and well tolerated. 2) Your choice of “science” tends to be largely opinion and you (possibly unintentionally) exert your bias onto its interpretation.

    Blue Wode wrote:
    “@ David: David wrote: “The fact is that the references you provide are *often* out of context, *often* not accurately described and *often* not even relevant to chiropractic as it is practised by the vast majority of chiropractors in the UK.”
    Often? Evidence please.”

    Is that an admission that you *have* presented references out of context, that you *have* described them inaccurately and that they *have* been irrelevant to the UK chiropractic practice? I know that your tendency is to distract by introducing other matters, but you generally like to argue a point if you think you can win it.

    I notice that you haven’t dealt with this matter:

    When you referenced “Fig 2″ in your earlier post, the point you were trying to make was that chiropractic manipulation of the neck is more dangerous than physiotherpy manipulation. However, that is not what the graph shows and the suggestion you make is a misrepresentation of the “evidence”. Whether this is mistaken or deliberate is open to speculation.

    While we’re at it, you still haven’t produced the evidence to substantiate your accusation that “my attitude” is any less cautious than is appropriate?”

    I haven’t got the time to go through and deal with every one of your points, but the truth is that there’s nothing new in there anyway. It’s all just the same old, recycled propaganda. It’s a shame you aren’t actually interested in proper debate of the issues.

  • Stefaan wrote: “…we are dealing with a market which is not being serviced by anyone.”

    That is not true. You are sharing a market that’s well serviced by therapists who offer similar interventions, e.g. physiotherapists, osteopaths, and sports trainers.

    Stefaan wrote: “Bearing in mind that it is almost a requisite for people to have tried conventional strategies prior to visiting us, it is crucial for you to appreciate that our viewpoint is developed from a lack of choice, rather than malice or economically/emotionally driven bias. It is driven by an appreciation for the fact that the people we see have run out of options and the price for them to pay is pain, disability and loss of earnings amongst others. In this context you appear to fail to recognise the clinical reality of the situation: evaluation of lack of evidence versus the price of doing nothing. As it stands the success rates are very high, or at least seem to be in the eyes of the patients, and they, after all is said and done are the ones happy to pay for our services, and happy to recommend us to others.”

    Stefaan, it’s worth noting what the late Barry Beyerstein, PhD, a well-respected scientist who worked in the Brain Behaviour Laboratory at Canada’s Simon Fraser University’s Dept. of Psychology, had to say in this excerpt from his paper ‘Social and judgmental biases that make inert treatments seem to work’…

    “Those who cast doubt on fringe treatments are frequently dismissed with the rejoinder, “I don’t care what your research studies say; I know it worked for me.”

    It is well established, however, that this kind of intuitive judgement often leads to seriously flawed conclusions. [56,57] Unfortunately, the typical purveyor and purchaser of unproven therapies is insufficiently aware of the many perceptual and cognitive biases that can lead to faulty decisions when we depend on personal experience to decide what has caused a disease or whether a therapy “has worked” or not.

    -snip-

    Psychologists interested in judgmental biases have repeatedly demonstrated that human inference is especially vulnerable in complex situations, such as that of evaluating therapeutic outcomes, which contain a mix of interacting variables and a number of strong social pressures.

    Add a pecuniary interest in a particular outcome, and the scope for self-delusion is immense.”

    More…
    http://sram.org/0302/bias.html

    I would urge you, and David, to take time to read that paper – all the way through to its conclusion which quotes Goethe: “Nothing is more dangerous than active ignorance.”

  • @ Andrew Gilbey

    Andrew Gilbey wrote: “@David,You wrote about Blue Wode, “Your interests seem to lie not in improving how musculoskeletal healthcare is practiced, but only in the demise of chiropractic. That’s called prejudice”
    Surely, it’s only prejudice if it is without grounds. I think the majority of skeptics actually have grounds to query the existence of chiropractic; for example, quality evidence suggests it isn’t very effective, proper EBM medicine is already practiced, it may do harm, a good many chiropractors make ridiculously misleading claims, the scientific rationale for spinal manipulation is not very convincing, the risible idea of vertebral subluxations, etc.”

    Please don’t feel offended Andrew, but it appears that you haven’t been paying attention.

    The quality evidence shows chiropractic to be at least as effective as anything else for the problems that chiropractors spend the massive majority of their time treating.

    “Proper” EBM isn’t any more evidence-based than chiropractic.

    There is no evidence that chiropractic is any more likely to do harm than any other branch of healthcare and the evidence that exists already shows it to be effective for the treatment of back pain, neck pain, headaches and dizziness etc.

    It is true that *some* chiropractors make misleading claims but that matter is being dealt with.

    There is a perfectly good scientific rationale for the use of spinal manipulation as part of the package that chiroprcators apply in the correction of joint and muscle function.

    You should have noticed that the vertebral subluxation complex has been looked at and dealt with by the GCC already.

    So, by your definition, if you have a negative view of chiroprctic on the grounds above, you are being prejudiced.

  • “With just enough of learning to misquote”
    Lord Byron
    Humility my dear, humility is the foundation of the phycisian’s position, and control is the temptress

  • @david

    You wrote, “The quality evidence shows chiropractic to be at least as effective as anything else for the problems that chiropractors spend the massive majority of their time treating.”

    We are talking lower back pain? Well isn’t simple exercise equally as good? That’s free and has associated benefits. I also thought physiotherapists are just as good. Arguing it’s no more likly to do harm than other forms of care is a logical fallacy. It’s not clear the claims of some chiropractors actually are being dealt with. I’m certain a good many chiropractors wil never let go the idea of the subluxation.

    You also wrote, “There is a perfectly good scientific rationale for the use of spinal manipulation as part of the package that chiroprcators apply in the correction of joint and muscle function.” I’m not convinced. Could you direct me to it?

  • @Sarah

    The article you cite is in an unreliable source, after reviewing scores of such articles I can safely say it is not worthwhile. If they had useful results they would have published in a good journal.

    Furthermore, it does not demonstrate correction of joint and muscle function in the only sense that matters- clinically. Rather, they played with somebody’s back and measured a brief, electronic response. It is the nature of chiro “research” to infer significant results from minor, laboratory observations such as those. Still, that is probably the best you can offer. History has shown that the better the research, the less favorable it is to chiro.

    Even for low back pain, the only arena in which chiro seemed about as good as all the alternatives, chiro seems to be losing its luster as more research accumulates.

  • @Sarah

    JJM provides a very good explanation. Personally, I would not give the time of day to a journal like that.

    I’d be interested if you can provide evidence from a journal that has an impact rating.

  • RE my last comment: I was actually thinking of the JVSR when I wrote my comment about JMPT. However, JJM’s comments about the article Sarah cites seem spot-on.

    I guess if there was any good evidence for chiropractic spinal manipulation it would deserve publication n a good journal

  • @ JJM
    JJM wrote: “The article you cite …. does not demonstrate correction of joint and muscle function in the only sense that matters- clinically.”

    Andrew Gilbey’s request was for direction towards a scientific basis for manipulation, not a clinical study.

  • @ JJm and Andrew Gilbey

    JJM wrote: “The article you cite is in an unreliable source, after reviewing scores of such articles I can safely say it is not worthwhile. If they had useful results they would have published in a good journal.”

    Andrew Gilbey wrote: “JJM’s comments about the article Sarah cites seem spot-on.”

    Have you read and understood the paper? Are you in a position to give an informed critique of it?

    If you are dismissing the paper merely on where it was published, then that I’m afraid is the very definition of prejudice.

  • @David

    You ask, “Have you read and understood the paper? Are you in a position to give an informed critique of it?”

    Good question, albeit rather patronising. Of course I’ve read the paper. Fortunately, I have institutional access to this journal and can access the whole article online. You also ask, “Are you in a position to give an informed critique of it?”. I think so: I get paid for doing so.

    @sarah pointed readers to the paper that can be found here: “http://www.ncbi.nlm.nih.gov/pubmed/16182019?dopt=Abstract as an answer to my question:

    “…There is a perfectly good scientific rationale for the use of spinal manipulation as part of the package that chiropractors apply in the correction of joint and muscle function.” I’m not convinced. Could you direct me to it?”

    The paper doesn’t provide the evidence I requested. First, there’s no control condition, so the same effect may be caused by other interventions or sham interrentions. Second, it may be a chance finding – it was seriously underpowered. And let’s not forget third, no mention of potential conflict of interests: it was conducted by chiropractors and internally funded by Palmer centre for chiropractic research.

    I found it a rather nasty little paper to read.

  • @ Andrew Gilbey

    Apologies if my tone sounded patronising. Handsomely put into perspective by your condescenion.

  • @David

    Just all part of debating. ;-)

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