Chiro evidence for subluxations pwned — by chiros!

When the British Chiropractic Association published its ‘plethora‘ of 29 references they thought supported chiropractic for childhood conditions, it took just 24 hours for it to be utterly demolished by scientists and skeptics. Only 18 of these were relevant to chiropractic and childhood conditions.

Shortly after that, Fiona Godlee, Editor on the BMJ, commenting on an article by Prof Edzard Ernst, said:

But in response to our recent editorial by Evan Harris (doi:10.1136/bmj.b2254), the vice president of the BCA, Richard Brown, has now presented the evidence (doi:10.1136/bmj.b2782). He writes, “There is in fact substantial evidence for the BCA to have made claims that chiropractic can help various childhood conditions” and lists 18 references. Readers can decide for themselves whether or not they are convinced. Edzard Ernst is not (doi:10.1136/bmj.b2766). His demolition of the 18 references is, to my mind, complete.

This, presumably, was the best evidence the BCA could muster and it was left in tatters by those more knowledgeable about science and robust trials.

Chiro wars

There have always been uneasy tensions between the different chiropractic factions with the ‘straights’ at one extreme, sticking to the ‘true chiropractic philosophy of the vertebral subluxation complex’ (VSC) and the ‘mixers’ and ‘medipractors’ at the other end, more than happy to try to muscle in on non-chiropractic areas such as prescribing drugs.

The GCC’s declaration about the VSC being no more than an ‘historical concept’ that 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.

has upset many chiropractors who have been earning their livings from finding subluxations in their customers and correcting them with ‘specific yet gentle chiropractic adjustments’.

There is now even an organisation to protect and promote the beleaguered subluxation, the Foundation for Vertebral Subluxation (cached). I’ve mentioned them before, but we need to look more closely at them. They say (cached) they are:

Dedicated to the Founding Principles & Tenets of the Chiropractic Profession

The chiropractic profession is in the midst of deep and serious changes. These changes are taking place in the larger context of health care and an even larger socio-cultural worldview that is not necessarily congruent with the founding principles and tenets of the chiropractic profession.

In other cases some of the original premises of the chiropractic profession are being co-opted by others as they come to see the value in the niche that chiropractic has carved out for itself.

During this tumultuous time it is ever more important that the profession hold fast to its unique and distinguishing features for these are all we really have claim to.

Beyond holding ground already gained there is a sense of urgency that the profession must seriously advance itself in the area of vertebral subluxation. The identification and care for this pathophysiological process is uniquely chiropractic and through research, education, policy and service we must ensure that we remain at the forefront of its elucidation.

Not surprisingly, they talk a lot about attacks on the VSC (cached):

It is time for the subluxation based community to seriously engage in matters of policy that affect the profession. A small, rogue splinter group has sought to fundamentally alter the very substance of the chiropractic profession in just a short time period. It is time for the majority of the profession which identifies with a subluxation based approach to exert itself and formulate, develop and implement policies that are congruent and supportive of the foundational principles and tenets of the profession.

Concluding:

A sick and suffering humanity needs us and we need you to join us on this mission.

A call to arms!

By ‘small, rogue splinter group’, I assume they mean the BCA even though all the chiropractic training establishments in the UK have also deprecated the subluxation even if all the chiropractic trade associations don’t quite agree.

One of the Directors of this august body and defender of the subluxation is Matthew McCoy DC, MPH (Masters of Public Health, apparently). He has his own website, McCoy Press, dedicated to:

…publishing progressive, health related content that will help push the needed paradigm shift in health care in the right direction. We are about rational, thoughtful and progressive discussions on the current health care crisis.

No doubt as part of this ‘rational, thoughtful and progressive discussion’ was an article titled I Think Their Heads Rattle When They Shake Them (cached).

He appears to be referring to the GCC.

He continues his ‘rational, thoughtful and progressive discussion’:

…just when you thought the General Chiropractic Council could not make more bizarre statements than they have already made – they provide more giggles and grins.

…

Scientism at its finest – or should I say worst since they can’t even seem to get the science right.

The bottom line is that the Golden Rule prevails here – He with the most gold – rules. And since the GCC has the gold in the way of the annual registration fees of the practicing chiropractors in the UK – they have the money to promote (ahem – enforce) their agenda.

However, McCoy highlights some correspondence (cached) between the GCC and an organisation called the Federation of Straight Chiropractors and Organisations (FSCO)

This correspondence is interesting.

They seem pretty convinced about the subluxation and its role in health, although geography obviously isn’t one their strong points:

The Federation of Straight Chiropractors and Organizations (FSCO) represents Doctors of Chiropractic whose objective in practice is the location, analysis and correction of vertebral subluxation for the betterment of health. We are writing at the request of our members internationally as well as those in the United States who are concerned with your recent position on the role of vertebral subluxation correction in chiropractic. Restricting the practice of chiropractic to the treatment of muscuioskeietai complains and physical therapy robs the public of a valuable health service (vertebral subluxation correction) and frankly duplicates the service of physical therapy in many instances.

Your most recent move to eliminate subluxation correction from the scope of practice in England [sic] is in direct conflict with the body of scientific literature as well as the standards of the chiropractic profession in virtually every other country chiropractors are licensed. Our concern is that the GCC has deviated from the standards our profession holds in the rest of the world, specifically in the United States. The Association of Chiropractic Colleges (ACC), Council for Chiropractic Education (CCE) as well as the National Board of Chiropractic Examiners (NBCE) all recognize vertebral subluxation as a vital component of our practice. In fact, our federal system of health care for senior citizens (Medicare) will not pay a submitted claim unless it is attached to a diagnosis of subluxation for the region of the spine being adjusted.

The aberrant effects of vertebral subluxation on health are well documented and inarguable. Attached to this document is a small sampling of literature demonstrating the effects of vertebral subluxation on physiology. To avoid any argument of bias associated with a particular journal or study design, we have included citations from both the chiropractic and medical literature. We ask that you consider the empirical evidence herein and make the appropriate changes to your position in a timely manner.

Our hopes are that after objective consideration of the facts presented the GCC will reconsider their position and that the people of England [sic] will have access to the service of vertebral subluxation correction.

Ah! Another…

Plethora!

This ‘small sampling of literature demonstrating the effects of vertebral subluxation on physiology’ consists of seven references. As ever, it is a ‘growing body of literature’:

There is a growing body of literature that support the subluxation model, a sampling of which is provided below (1-7).

1. Sato A, Swenson RS. Sympathetic nervous system response to mechanical stress of the spinal column in rats. Journal of Manipulative Physiological Therapeutics 1984; 7(3):141-7.
2. Dishman R. Review of the literature supporting a scientific basis for the chiropractic subluxation complex. Journal of Manipulative and physiological Therapeutics 1985; 8(3):163-174).
3. Mañno MJ, Langrell PM. A longitudinal assessment of chiropractic care using a survey of self-rated health wellness & quality of life: A preliminary study. Journal of Vertebral Subluxation Research 1999; 3(2):1-9.
4. Bolton PS. Reflex effects of subluxation: the peripheral nervous system. Journal of Manipulative Physiological Therapeutics 2000; 23(2): 101-103.
5. Budgell BS. Reflex effects of subluxation: the autonomic nervous system. Journal of Manipulative Physiological Therapeutics 2000; 23(2): 104-106.
6. Bakris G, DickholtZ M Sr, Meyer PM, Kravitz G, Avery E, Miller M, Brown J, Woodfield C, Bell B. Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study. Journal of Human Hypertension 2007;21 (5):347-52.
7. McAllister W, Boone WR, Power K, Hart J, Xiong T, Westbrook M. Chiropractic Care and Changes in Physical State and SelfPercePt10n5 in Domains of Health among Public Safety Personnel A Longitudinal Follow up Study. Journal of Vertebral Subluxation Research 2009; [May 151: 1-11.

I assume this sample reflects the pinnacle of the research into the subluxation and representative of all the evidence — why would they provide any poor quality references?

For the avoidance of doubt

But before we look at the GCC’s response to this plethora, it’s worth noting what Margaret Coats says in her reply to the FSCO:

For avoidance of doubt, your attention is drawn in particular to the fact that both these documents are concerned with the level of clinical research evidence that is required in respect of advertised claims for chiropractic care in the UK. They do not focus on scope of practice.

For the avoidance of doubt, this is only to do with what chiropractors claim they can do and has nothing to do with what they actually do in practice.

Demolition

This is certainly another plethora that needs close examination. After all, there is always the possibility that there may, indeed, be good, persuasive evidence for the subluxation.

Do we need to gather the best minds in science to review all these references? Perhaps we need to call on the expertise of Prof Edzard Ernst?

No. These references have already been reviewed. The GCC got the Anglo-European College of Chiropractic, no less, to review them.

So, was this a whitewash, with chiropractors all agreeing amongst themselves about the mountain of evidence for the subluxation?

Not exactly. In fact, the best evidence put forward by the straight chiropractors was pwned. Utterly. By fellow chiropractors.

1. …The major flaws in this paper render it a very poor paper, which should not have been published. This paper does not support the contention that the VSC has an effect on health and that the correction of this putative lesion can have an impact on health.
2. …This study suggests that upper cervical manipulation may be an adjunctive treatment to medication for patients with mild hypertension, but does not address the concept of health promotion or wellness.
3. …This paper does not support the contention that the VSC has an effect on health and that the correction of this putative lesion can have an impact on health.
4. …This literature review can in no way be construed to support the concepts of the health and wellness benefits of correcting putative vertebral subluxations. Only well-conducted randomised controlled trials are able to test this concept.
5. …This literature review can in no way be construed to support the concepts of the health and wellness benefits of correcting putative vertebral subluxations.
6. …While this interesting study suggests force applied laterally to the spine may affect certain physiological parameters it does not support the concept that the putative vertebral subluxation complex has a health promoting effect. Only randomized controlled clinical trials are able to answer this question.
7. …This is an interesting paper that presents possibilities and cannot be seen as adding support to the concept that correcting the vertebral subluxation complex has health promoting effects. Again, the only way to definitively show if the putative spinal lesion has health promoting effects and is as dangerous as some claim is through clinical trials using a randomized controlled design.

To steal the phrase from Fiona Godlee:

The demolition of the seven references is, to my mind, complete.