Getting their nappies in a twist

It had never occurred to me that one of the important design parameters of a nappy would be how little noise it makes when flexed.

However, this seems to be a USP for some manufacturers and they want to tell prospective customers all about it.

Proctor and Gamble (P&G) manufacture Pampers, and one of the products in their range are UnderJams:

UnderJams pyjama pants give your child all the privacy and protection they need if they tend to wet the bed. They’re specially designed with an absorbent core to help protect from leaks, and are made from quiet materials to reduce any embarassing [sic] ‘rustling’ sound.

I can sort of see that the sound they make might be important to a child.

P&G decided to advertise this particular feature of their UnderJams and they claimed:

UnderJams are the quietest Pyjama Pant. Kids get the all-night protection they need without the whole world having to know.

The claim about being the quietest is an absolute and not a qualified claim, so one of P&G’s competitors, Kimberley-Clark, who manufacture Huggies DryNites Pyjama Pants, complained to the Advertising Standards Authority (ASA), challenging whether P&G’s claim was misleading and could be substantiated. The ASA adjudication was published yesterday.

Evidence

P&G produced their evidence to back up their claim:

Procter & Gamble (Health & Beauty Care) Ltd (P&G) said the claim was based on extensive testing, the most recent of which was undertaken in January 2010, during which a direct comparison was made with the complainants products: Huggies DryNites Pyjama Pants and DryNites Sleep Shorts; the results of the testing showed UnderJams were significantly quieter. They said they had also carried out consumer research, which showed that 93.3 per cent of 60 panellists preferred UnderJams to DryNites Pyjama Pants because they were quieter; 96.2 per cent of 53 panellists preferred the product to DryNites Sleep Shorts for the same reason. They said the level of noise created by pyjama pants was important because privacy was well known as one of the key concerns of bedwetting children. P&G submitted the results of the 2010 testing and consumer research as well as of consumer and technical research they had conducted in 2008 and of technical research conducted in 2009, which they believed also supported the claim.

Unpacking that a bit, P&G’s evidence amounted to comparative testing done in January 2010; consumer research carried out in 2010; consumer and technical research carried out in 2008 and technical research carried out in 2009.

As an aside, it’s interesting to see how they measured the noise from a nappy. They measured:

…the decibel levels generated by twisting each product, which was intended to simulate the sound created by the product in use.

However, it’s not entirely clear when the advert was published and when Kimberley-Clark complained, but the ASA had an issue with some of this evidence:

The ASA noted the most recent consumer and technical testing was conducted after the ad appeared. The CAP Code stated, however, that documentary evidence to prove all claims should be held by marketers before marketing communications were submitted for publication. Because the evidence submitted was collated after the ad appeared, in January 2010, we considered it was not admissible as substantiation for the claim under the CAP Code and did not analyse it in detail. We considered it was not acceptable to retrospectively seek substantiation for a claim.

They went on to examine the other evidence supplied, but upheld the complaint:

The ad must not appear again in its current form. We told P&G to ensure they held robust substantiation, before an ad was submitted for publication, to support future claims.

There are lessons to be learned here. Evidence for a claim established after you’ve published that claim is not acceptable — the advertiser must hold the evidence at the time of making the claim.

ASA guidance

How does this relate to my complaints to the General Chiropractic Council? (Well, it had to, didn’t it?)

You may remember that the GCC’s Investigating Committee (IC) decided that most of my complaints were being referred to the Professional Conduct Committee (PCC) after considering the requirements of The Consumer Protection from Unfair Trading Regulations 2008.

However, for some unexplained reason, they appear to have considered only one half of clause C1.6 of the Code of Practice:

[Chiropractors] may publicise their practices or permit another person to do so consistent with the law and the guidance issued by the Advertising Standards Authority. (My emphasis)

There was no mention of any consideration of the ASA guidance, but it may be worth speculating on the reasons by considering the issues that might have been raised if they had taken the ASA guidance into account as mandated by their Code of Practice.

The main points of the ASA guidance that they would have to have taken into consideration can be summarised as:

  • the advertiser is required to hold substantiating evidence for claims made;
  • the advertiser must hold that evidence at the time the ad is placed;
  • the advertiser has to supply that evidence on request;
  • that evidence has to be robust evidence from relevant, randomised, controlled, double-blind clinical trials.

Too little, too late

One has to wonder just how much of the ‘evidence’ in the Bronfort Report — a lot of which had little to do with chiropractic manipulations — would meet that last requirement. Certainly, what was said about ear infections doesn’t stand up well to scrutiny.

They could, of course, just have had a look at what the ASA allowed (or even consulted them). The ASA have a different list of allowable claims, of course, built up from robust scientific evidence and what the GCC should have taken into consideration in determining the fate of my complaints, as well as any new robust evidence any chiropractor was able to supply. However, it’s clear to me that this ‘evidence’ (included with the observations on my complaint) would not have been looked on favourably by the ASA as attempts at substantiation.

But what the P&G adjudication makes clear (as if it wasn’t already) is that the advertiser must hold the robust evidence at the time the claims are made. Indeed, to comply with ASA guidance, they should have held the evidence of substantiation when they first published the claims on their websites. Digging it up after publication breaches the ASA’s guidance. Remember, in the P&G complaint, the ASA said:

We considered it was not acceptable to retrospectively seek substantiation for a claim.

It’s not just P&G who are getting their nappies in a twist.

133 thoughts on “Getting their nappies in a twist”

  1. Just a minor correction – Underjams are not marketed at toddlers, but at older children who still occasionally wet the bed. This is embarrassing enough without having to wear obvious, rustly underwear, especially if it’s (say) a sleepover.

    So I wouldn’t scoff – non-rustling underwear is in actuality a valuable USP in this market.

    Now as to whether they can back up the quietness claims, that’s a whole other kettle of rabbits…

  2. Interesting, I suppose.

    However, I guess the only important point is, are Underjams actually quieter than DryNites? If they are, the public has not been misled and there is no harm done.

    Is chiropractic helpful in the management of the whole range of musculoskeletal conditions? Yes it is. Has that yet been proved in RCTs for each and every manifestation of musculoskeletal dysfunction? No it hasn’t. Doesn’t mean that chiropractic claims are invalid, only unproven.

    So, you can use every technical aspect you can find to try and put the GCC in as difficult a position as possible but at the end of the day, what matters is whether the public has been misled, not whether the evidence came before or after the claims.

  3. David

    CAP Code 3.7 requires:
    Before distributing or submitting a marketing communication for publication, marketers must hold documentary evidence to prove claims that consumers are likely to regard as objective and that are capable of objective substantiation.
    Requiring an advertiser to hold evidence before publishing a claim, is not some technicality; it is an integral part of the CAP Code. Not having robust substantiation of the claims at the time of making those claims is a breach of the CAP Code and misleads the public.

    Your point about chiropractic being unproven rather than invalid is irrelevant. The GCC’s CoP does not say that any old evidence is all that is required; like it or not, it says it must comply with the ASA guidance and the law.

    If chiropractic is unproven to the standard required by the ASA, that is a breach of the CAP Code and therefore a breach of the GCC’s CoP and misleads the public.

  4. I suspect the reason the GCC are quoting trading standards rather than ASA guidance is that the ASA/CAP code do not (until March 2011) apply to websites. It would be perverse to try and apply guidance aimed at copy advertising to a quite different media type that itself will require specific guidance. This is not inconsistent with the GCC code as when asked for guidance on websites the CAP people simply tell you that the code does not apply – that is their guidance/advice at present.

    On the evidence base what makes you believe that the ASA have seen robust evidence for any form of manual therapy?

    The list of conditions that can be adertised by chiropractors, osteopaths and physiotherapists is laughable and out of date. I think you will find that this is largely untested and this will have significant implications for all of the above professions and perhaps more importantly the ASA themselves.

    As for asking for double blind studies (where both the practitioner and patient are unaware of whether the treatment is real or placebo control) this illustrates a fundamental misunderstanding of how to assess outcomes with manual therapies.

  5. Andy said:

    I suspect the reason the GCC are quoting trading standards rather than ASA guidance is that the ASA/CAP code do not (until March 2011) apply to websites.

    The ASA will certainly not be applying the CAP Code rules to websites for another six months, but the GCC’s CoP says that chiropractors must publicise their practices consistent with ASA guidance.

    It would be perverse to try and apply guidance aimed at copy advertising to a quite different media type that itself will require specific guidance.

    Not so. The CAP Code already applies to some online advertising:

    Advertisements on the Internet, including banner and display ads and paid-for (sponsored) search

    Also, the CAP Code rules themselves are not changing, so the current rules are the ones that will universally apply to advertisers’ own websites next year.

    This is not inconsistent with the GCC code as when asked for guidance on websites the CAP people simply tell you that the code does not apply – that is their guidance/advice at present.

    The GCC’s CoP clearly binds chirpractors to being consistent with ASA guidance — the form of that publicity is not restricted by the CoP, therefore it must apply to all advertising.

    On the evidence base what makes you believe that the ASA have seen robust evidence for any form of manual therapy?

    We know they have adjudicated on several chiro advertising complaints and found some OK (and some to be in breach). Of course, other than that, I have no way of knowing what evidence they have seen.

    The list of conditions that can be adertised by chiropractors, osteopaths and physiotherapists is laughable and out of date. I think you will find that this is largely untested and this will have significant implications for all of the above professions and perhaps more importantly the ASA themselves.

    Perhaps their list is out of date — but they have adjudicated on several chiro complaints, including — embarrassingly — on a GCC leaflet. I do know, though, that they are looking at the Bronfort Report and may change their advice as a result.

    As for asking for double blind studies (where both the practitioner and patient are unaware of whether the treatment is real or placebo control) this illustrates a fundamental misunderstanding of how to assess outcomes with manual therapies.

    The ASA will consider only robust evidence from relevant, randomised, controlled, double-blind clinical trials and we know the GCC has interpreted the ‘relevant law’:

    In the context of the relevant law (The Consumer Protection from Unfair Trading Regulations 2008) advertised claims for chiropractic care must be based on best research of the highest standard. This will almost certainly mean randomised controlled trials that produce high or moderate positive evidence.

    Of course there are issues with double-blinding, but that’s something for researchers to figure out — there are ways of minimising the risk of bias to ensure the subject is unaware of what treatment is being delivered. This has to be done so we can be sure that claims of efficacy are attributable to chiropractic and not bias. However, many trials I’ve seen cited by chiropractors weren’t even single-blinded (or controlled, or randomised, or sometimes even relevant to chiropractic).

    Regardless, the GCC have passed the majority of my complaints to the PCC, so we will need to see what happens next.

    However, if chiropractors want to convince the ASA, they had better start producing some robust evidence to back up claims. The clock is ticking.

  6. The odd thing is that they’ve told P&G not to run the ad again “in its current form” – but P&G now have the evidence which would surely make future ads valid.

    This is one of the problems with a “no-penalty” compliance system, however. We see it here in Oz too. The “no further ads” warning does not assist those customers persuaded, perhaps wrongly, by any shonky ads that have already appeared. So it is in the advertiser’s best interest to have a quick campaign blitz, maximise early sales and cement a position in people’s minds as to the product’s supposed benefits – before the adjudicators tell them to stop doing it.

    What have they got to lose? Reputation??!!

  7. Having a third person do the assesment of effectiveness enables effective blinding of manual therapies. Double blinding requires that the patient not know which treatment they are getting, and the assessors not know which treatment the patient got. The person doing the treatment itself can know, provided they do not tell the patient and do not do the assessment of effectiveness. The control treatment can be a general massage or some known ineffective intervention.

  8. AndyD said:

    The odd thing is that they’ve told P&G not to run the ad again “in its current form” – but P&G now have the evidence which would surely make future ads valid.

    The ASA said that they did not examine the inadmissible evidence in detail, so we don’t know whether that evidence validates the claims or not.

    davidp:
    Well said. These things are not that difficult, but it is surprising how little even half-decent trials of chiropractic seem to be taking place. Take a look at what ‘research’ is going on at the AECC, for example:

    * Prevalence of low back pain (LBP) in rotary wing aviation pilots.
    * Comparison of the posture of school children carrying backpack versus pulling them on trolleys.
    * The actions of chloride channel blockers, barbiturates and a benzodiazepine on Caenorhabditis elegans glutamate- and ivermectin-gated chloride channel subunits expressed in Xenopus oocytes.

    There does seem to be some research into the best ways to measure outcomes but surely there is already much research on this from other areas? Isn’t there some basic chiropractic research being missed?

  9. Zeno wrote:

    One has to wonder just how much of the ‘evidence’ in the Bronfort Report — a lot of which had little to do with chiropractic manipulations…

    It has been pointed out many times that chiropractic involves much more than just manipulation. It’s about time this was acknowledged.

    Zeno wrote:

    But what the P&G adjudication makes clear (as if it wasn’t already) is that the advertiser must hold the robust evidence at the time the claims are made. Indeed, to comply with ASA guidance, they should have held the evidence of substantiation when they first published the claims on their websites…

    Remember that although the Bronfort report was published in 2010, the evidence it examined all existed prior to the date that Zeno made his block complaint. It therefore remains admissable and relevant. Do bear in mind also that the Bronfort report is by no means comprehensive.

    Zeno wrote:

    Your point about chiropractic being unproven rather than invalid is irrelevant.

    This statement exposes the whole business of this blog. If it was genuinely about public safety rather than scoring points against chiropractors and the GCC, the only salient issue would be the validity of the claims, not whether you can find technical points that allow them to be used as ammunition.

  10. David said:

    It has been pointed out many times that chiropractic involves much more than just manipulation. It’s about time this was acknowledged.

    You mean a bit of massage as well?

    Remember that although the Bronfort report was published in 2010, the evidence it examined all existed prior to the date that Zeno made his block complaint. It therefore remains admissable and relevant.

    Did the chiropractors hold the necessary evidence when they made the claims?

    Do bear in mind also that the Bronfort report is by no means comprehensive.

    What do you think Bronfort missed out?

    This statement exposes the whole business of this blog. If it was genuinely about public safety rather than scoring points against chiropractors and the GCC, the only salient issue would be the validity of the claims, not whether you can find technical points that allow them to be used as ammunition.

    My blog is whatever I decide to make it, but that is irrelevant. However, what is relevant is the validity of the claims being made by chiropractors. The GCC are finally dealing with that issue.

  11. Prior to the BCA suit against Simon Singh I knew nothing of Chiropractic or Chiropractics other than the vague notion that they did back cracking. If I had encountered persistent back pain I might had considered visiting one.

    I happened to read Simon Singh’s “Code Book” when it was first published and had found it very interesting and felt it to be a best effort “scientific” discussion. I think I had subsequently seen some of his TV programs.

    So:- suddenly this man who I felt was a genuine and straightforward person is being assailed by people who seem to think that by giving a bit of a back rub that they can cure childhood ear infections (and apparently limitless other ailments). I am not a trained medical person however I have the idea that the mechanism that is *accepted* to cause such infections is based on some sort of microbes invading a convenient (to them) part of the body and then doing their best to devour it.

    There is simply no plausible mechanism available to explain how and why a back rub could possible influence such an infection. My immediate impression was that chiropractors cared as much for their patients as insurance salesmen did for their clients or as much as double glazing salesmen did for their targets.

    No subsequent event had given me reason to change that impression.

    It appears to me that chiropractors are simply targeting vulnerable members of our society and trying to squeeze money from them on the basis of some sales spiel developed over a century ago. My guess is that Mr Palmer probably ran out of money and could not afford to make his snake oil so he invented snake rubs instead. See the advantage – no stock needed. Snake oil free snake oil. Pure profit all the way to the bank. Zero “cost of sales”. What a superior business.

    All this bluster that “science is not good enough to understand our special magic” is simply that – BLUSTER. Empty, meaningless, stupid, bluster. No one with a clue will ever fall for it.

    Science has permitted man to go to the moon, has developed antibiotics, has developed vaccines, has engineered cheap global travel, has engineered cheap global transportation of food, has stopped billions of people from EVER being hungry. Oh and has cured (well under western medical care no one needs to die any more) AIDS.

    *YET*

    Chiropractic apologists say, “oh oh oh oh oh – none of this is relevant, we are too special for science to understand us.

    Well bollocks to you.

    It is self-evident rubbish. Hopefully, soon, proper regulation of this poisonous trade will eliminate it from our shores. The GCC seems woefully inadequate for the job, however someone appears to have found a rod for their back, so maybe soon, they will develop the insight needed to realise that they simply need to disband themselves:) Sort of a reverse boot-strap? Bury yourself with your own boot straps?

    There is no place in our society for such witch doctors.

    Let me now assure you that after assessing the available evidence (including the Bromfort Report) I will never consider visiting such a witch doctor and will do everything in my power to dissuade anyone I know from ever visiting one either.

    If you are a practising chiropracticor the most honourable thing you can do is to prevent any more young people from being sucked into your now time limited trade. Please campaign to close down all of the remaining witch-doctor courses. I am sad that many chiropractors may have been duped into a particular career path however the finish of it is now in your hands.

  12. James Jones – You are wrong! I absolutely disagree with you where you say, “No one with a clue will ever fall for it.” Unfortunately there seems to be to be quite a lot of people who do seem to have a clue and who do fall for it.

    Regarding everything else, I absolutely agree!

  13. David said:

    It has been pointed out many times that chiropractic involves much more than just manipulation. It’s about time this was acknowledged.

    To which Zeno said:

    You mean a bit of massage as well?

    That is just a bit silly isn’t it? Manipulation is one of many techniques available to achieve a desired effect. On a vertebral level, manipulation is one of the most powerful non-surgical ways of altering local motion and range of motion (quality and quantity). Used at regular intervals it does seem to have the ability to recondition movement patterns (output) and the best and most plausible theory I feel is that it does that as a consequence of response to altered input. Self-organising neural networks is the idea you’re looking for. Surgery and pharmacology are of course great, but you probably do see the sense in at least trying to figure out why the tissues are inflaming, particularly if it’s not a one-off event or due to pathology/trauma. You see Zeno, “the back rub” is not to cure all ills as is sometimes idiotically stated (mostly by misrepresenting entities), the chiropractic approach is one of addressing casual mechanisms when such mechanisms are present and when removing such causal mechanisms has enough of a chance of being sufficient to result in significant functional and symptomatic recovery. So that means that in order to interest a chiropractor there has to be static causation (as opposed to transient in which case it should be expected to make natural unaided recovery), not just symptomatology.
    James Jones said:

    assailed by people who seem to think that by giving a bit of a back rub that they can cure childhood ear infections (and apparently limitless other ailments)

    No, not quite. I think you have your sources mixed-up. Chiropractors don’t give a bit of a backrub and expect limitless ailments to be cured in so doing. I suspect you’re being a little extravagant in your claims. I refer you to the comment above regarding Zeno’s “backrub” comment, but I would like to respond more specifically to the point you raise (ear infection) by commenting that the problem with studying the impact of the chiropractic approach to ear infections is hugely complex and is strewn with, amongst others, the following issues:
    It is likely that any relevance between chiropractic techniques and a perceived benefit in certain cases of otitis media relates to cranio-facial dynamics causing changes in the width and aeration of the Eustachian tube. Such variations present a theoretical but very plausible (and in the infant and young child even very likely) variation in frequency of otitis media. Not because of some inexplicable anti-biotic effect of chiropractic manipulation or adjustment, but rather because of a widening of the Eustachian tube and the ensuing improved aeration making the inner ear a less active breeding ground. The same should in theory be true of sinusitis-related infections.
    In this sense, the difficulty with ascertaining likelihood of success with treatments effecting cranio-facial dynamics, lies in the clinician’s ability to distinguish with high level of certainty that it is indeed a problem with musculo-skeletal dynamics in the skull which are contributory cause (alone or aggravated by yet other factors) of the presenting case of ear infection.
    Another difficulty resides in making sure than one is applying the correct form of treatment to elicit the correct change in cranio-facial dynamics.
    and:

    There is simply no plausible mechanism available to explain how and why a back rub could possible influence such an infection.

    I hope you now understand that there is. No-one is arguing that there isn’t a bacterium involved in this equation. Just that this bacterium is more likely to breed successfully with a narrow Eustachian tube. And that certain cranio-facial dynamics predispose to a narrowing of the Eustachian tube. And that chiropractors (and other affiliated fabulous people) can affect certain types of dysfunctional cranio-facial dynamics resulting in alteration of the diameter of the Eustachian tube in those cases where the two are related (which will only be a proportion of cases and in consequence the idea of “treating a symptom” is completely ridiculous within the chiropractic philosophy as not all symptomatic displays will have the same mechanism at their root-the genius of pharmacologically and surgically based healthcare is that they by-pass the need for functional and physiological agreement within the body-the genius of chiropractic healthcare is that it tries to never let things get so far that those are the only options left).
    James Jones’ observes:

    It appears to me that chiropractors are simply targeting vulnerable members of our society and trying to squeeze money from them on the basis of some sales spiel developed over a century ago

    You see, this is interesting, these

    vulnerable members of our society

    referred to here are usually well-educated, well-paid and want to get better. They don’t care why it works, just that it works. They keep us in business by referring 500 patients to my clinic alone each year (and climbing). What matters to them is that for 2010 there’s only been one patient who did not achieve the results they were promised at the onset…

    All this bluster that “science is not good enough to understand our special magic” is simply that – BLUSTER. Empty, meaningless, stupid, bluster.

    erhm, no it’s not that “science” is not good enough (I think you are mistaking chiropractic for colourfairycrystalographicfield-healing) it is that the scientific method, to be more specific the RCT method of science, is very expensive and complex to run for something so multi-factorial. Even for something apparently as straightforward as “simple back pain”. In the face of a situation where lots of people are keeping us busy without having to provide the evidence so craved, it will be understandable that this is not the priority. It would be nice, but it doesn’t really matter. Finally on this quote, for a self-confessed medically untrained person, James Jones expresses some very, very strong views on something he knows really very little about

    Well bollocks to you.It is self-evident rubbish. Hopefully, soon, proper regulation of this poisonous trade will eliminate it from our shores.

    Strong words indeed, particularly at the address of the first primary care profession to be able to guarantee outcome measures, populated by people trained to MSc. And PhD. level in UK Universities! It is awfully self-indulgent of me but unfortunately I feel James Jones expresses here sentiments based on a, locally oft-shared, lack of information and understanding of the subject matter. I trust this has been rectified in this post.

    There is no place in our society for such witch doctors.

    Ehm, yes there is. But then what you call witchcraft is what we call treating patients with some basic common sense: treat the cause, not the symptom (when this is feasible with the available tools and responsible) and watch them get better. It is just unfortunate that the mistake so commonly made here and on other similar blogs is to assume that the chiropractic “subluxation” is a clinical entity. It is not. It is however a group name for causes of dysfunctional movement patterns, some of which are vertebral in origin, some of which are not. The mistake some chiropractors make is to betray their core philosophies just to please a bunch of people who think they have a valid point just because they cannot differentiate between the pursuit of truth and the defence of the doctrine they are most acquainted with.
    Many kind regards,
    Stefaan

  14. @ James Jones

    As your comment is one of the finest that I’ve ever seen about chiropractic, I’m not surprised that it has elicited a highly defensive reaction from a young, practicing chiropractor.

    Stefaan Vossen wrote:

    “It is likely that any relevance between chiropractic techniques and a perceived benefit in certain cases of otitis media relates to cranio-facial dynamics causing changes in the width and aeration of the Eustachian tube. Such variations present a theoretical but very plausible (and in the infant and young child even very likely) variation in frequency of otitis media.

    Nevertheless, is it ethical that chiropractors should be extracting a fee for treating otitis in children when the current evidence does not support it as an intervention? For example, the British Chiropractic Association’s recent pathetic attempt to find supporting evidence for it was completely demolished here:
    http://tinyurl.com/ltwvz7

    And that critique is backed up by Ernst’s subsequent findings:

    Re: Chiropractic for otitis?

    Sir,

    Many professional organisations of chiropractic such as the British Chiropractic Association (1), the Chiropractic Association of Ireland (2) or the American Chiropractic Association (3) state or imply that chiropractic is an effective treatment for ear infections. A recent survey furthermore demonstrates that 54% of UK chiropractors subscribe to this idea (4). So is there any evidence that it is true?

    In an attempt to find all clinical trials on the subject, I conducted electronic literature searches in the following databases: Medline, Embase, Cinhal and AMED (September 2008). No language or time restrictions were imposed. To get included, an article needed to refer to a controlled clinical trial of chiropractic for ear infection (otitis). Case reports, case series and uncontrolled or feasibility studies were excluded.

    These searches generated 35 hits. After removing duplicates, 27 articles were read. None of them met the inclusion criteria. Previous research has shown that professional chiropractic organisations ‘make claims for the clinical art of chiropractic that are not currently available scientific evidence…’ (5). The claim to effectively treat otitis seems to be one of them. It is time now, I think, that chiropractors either produce the evidence or abandon the claim.

    E. Ernst
    Complementary Medicine,
    Peninsula Medical School,
    25 Victoria Park Road,
    Exeter EX2 4NT
    UK

    References

    1. British Chiropractic association, 2009.
    2. Chiropractic Association of Ireland, 2008.
    3. American Chiropractic Association, 2009
    4. Pollentier A, Langworthy JM. The scope of chiropractic practice: a survey of chiropractors in the UK. Clin Chiropractic 2007; 10: 147-55.
    5. Grod JP, Sikorski D, Keating JC. Unsubstantiated claims in patient brochures from the largest State, Provincial, and National Chiropractic Associations and Research Agencies. J Man Phys Ther 2001; 24: 514-9.

    Chiropractic for otitis? Int J Clin Pract, September 2009;63(9):1392-1393
    http://tinyurl.com/32uc96x

    Stefaan Vossen wrote:

    “These vulnerable members of our society referred to here are usually well-educated, well-paid and want to get better. They don’t care why it works…”

    …which is a great pity since most of them could avoid risking their time and money (and, in some cases, their lives) if they were somehow made aware of the following errors of reasoning which are frequently made with alternative medicine:
    http://www.sram.org/0302/bias.html

  15. Stefaan

    Blue Wode’s response is unsurprising and very typical. Because he does not have a true understanding of chiropractic and does not, as far as we can ascertain, have any clinical knowledge or experience on which to draw, he is unable to engage in the matter of the machanisms you describe. So he doesn’t.

    As ever, his agenda appears to be only to promulgate negative propaganda at any given opportunity. It’s interesting that we still haven’t had an answer regarding whether his previous misrepresentation of research has simply been a result of his incorrect interpretation of the results, or deliberate deception. For those interested in refreshing their memories, the exchange can be found here: http://www.zenosblog.com/2010/07/the-beginning-of-the-end-part-two/comment-page-2/#comment-7594

  16. @ James Jones

    James Jones wrote:

    There is simply no plausible mechanism available to explain how and why a back rub could possible influence such an infection. My immediate impression was that chiropractors cared as much for their patients as insurance salesmen did for their clients or as much as double glazing salesmen did for their targets.

    James, it’s very sad that your impression of chiropractic has been moulded in such an unfortunate way. In case you are interested, in the years that I have been pracitising, of all the many thousands of patients I have seen, the total number that I have treated for otitis media (ear infections) amounts to zero. These sorts of conditions make up a minute part of chiropractic practice and in my case, no part at all.

    I spend all day every day working to improve my patients’ lives by correcting musculoskeletal dysfunction. There are often far-reaching, and sometimes surprising, benefits to the patient’s overall health, but this is simply a corollary of improved neuromusculoskeletal function.

    I’m afraid that your diatribe, and that is what it is, reveals that your understanding of chiropractic must have been gained from sources such as this blog and its naysaying contributors. Sadly, these are not reliable sources.

  17. @ James Jones
    Congratulations on hitting a nerve or two with the practicing chiropractors commenting here. It’s very telling that they aren’t able to provide any decent evidence for their interventions beyond that of short-lived pain relief in a sub-group of low back pain sufferers (and even then, it should be remembered that spinal manipulation isn’t any more effective than cheaper, more convenient, and safer options).

    David wrote:

    “Blue Wode’s response is unsurprising and very typical. Because he does not have a true understanding of chiropractic and does not, as far as we can ascertain, have any clinical knowledge or experience on which to draw, he is unable to engage in the matter of the machanisms [sic] you describe. So he doesn’t.”

    Why bother when impartial expert evaluations increasingly point to chiropractic being supported only by a very meagre, and dare I say, diminishing, amount of evidence?

    David wrote:

    “As ever, his agenda appears to be only to promulgate negative propaganda at any given opportunity.”

    As I have told you before, I am for the provision of factual and accurate information in order that the public can make fully informed choices about their healthcare. Commonsense would demand that such information be sought from a source other than chiropractors, most of whom earn their livings in private practice.

  18. Blue Wode wrote:

    Congratulations on hitting a nerve or two with the practicing chiropractors commenting here.

    That’s a telling remark. Goes to show that what matters to Blue Wode is scoring points. But then we knew that already.

    Blue Wode wrote:

    It’s very telling that they aren’t able to provide any decent evidence for their interventions beyond that of short-lived pain relief in a sub-group of low back pain sufferers…

    It should be remembered that there is at least as much evidence to support the chiropractic management of the problems that chiropractors spend their time treating (musculoskeletal disorders), as there is for any other type of management. Of course, Blue Wode knows that but would rather have you believe otherwise.

    Blue wode wrote:

    …it should be remembered that spinal manipulation isn’t any more effective than cheaper, more convenient, and safer options…

    As has been stated ad nauseam, chiropractic involves much more than manipulation. It encompasses all the elements of best practice for the management of musculoskeletal disorders, particularly spinal pain. But of course Blue Wode knew that already.

    We’ve looked at this oft-trotted phrase about effectiveness, cost, convenience and safety, and Blue Wode’s statement is simply not true. But of course he knew that already.
    Readers are welcome to review the exchanges here: http://www.zenosblog.com/2010/07/the-beginning-of-the-end-part-two/comment-page-2/#comment-7360

    Blue Wode wrote

    Commonsense would demand that [factual and accurate] information be sought from a source other than chiropractors, most of whom earn their livings in private practice.

    Commonsense would demand that factual and accurate information regarding orthopaedic surgery should be sought from orthopaedic surgeons. That factual and accurate information regarding dentistry should be sought from dentists. That factual and accurate information regarding veterinary practice should be sought from vets. That fctual and accurate information regarding chemotherapy should be sought from an oncologist. That factual and accurate information regarding chiropractic should be sought from a chiropractor, rather an anonymous, apparently completely unqualified blog contributor with an obvious anti-chiropractic agenda.

    The little finishing touch on Blue Wode’s quote about private practice is very typical. Readers should remember that everyone in healthcare gets paid for what they do. Your GP gets paid for what they do. Your dentist gets paid for what they do. I could go on, but I’m sure you get the message.

    Of course, Blue Wode would like you to believe that chiropractors do their work only for the money but there again you would expect that from him. We have of course been here before when Blue Wode has made bald allegations of dishonesty, but has not produced the evidence to back it up. In case readers aren’t aware, on 30th June Blue Wode wrote:

    I am for freedom of informed choice.

    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.

    My respoonse was:

    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.

    Of course we never have had the evidence.

    As expected, we also have yet to get the answer as to whether Blue Wode’s previous misrepresentation of evidence was simply an example of him not understanding the research, or a deliberate deception.

    Blue Wode wrote:

    As I have told you before, I am for the provision of factual and accurate information in order that the public can make fully informed choices about their healthcare.

    I don’t think so.

  19. David wrote:

    Congratulations on hitting a nerve or two with the practicing chiropractors commenting here.

    That’s a telling remark. Goes to show that what matters to Blue Wode is scoring points. But then we knew that already.

    So, are you saying that my succinctly put support for James Jones is unwarranted, that his claims are incorrect, and that he hasn’t rattled you and Stefaan with his ability to through all the chiropractic bluster and to express, very well IMO, what he sees?

    David wrote:

    It should be remembered that there is at least as much evidence to support the chiropractic management of the problems that chiropractors spend their time treating (musculoskeletal disorders), as there is for any other type of management.

    Ah, but not only does chiropractic tend to be vastly more expensive and inconvenient than other options (and in some cases, less safe), it also continues to be mired in quackery. Indeed, at least half of the chiropractic population in the UK seem to not want to let go of its quackery:
    http://www.chiropracticlive.com/?p=842

    It would be very interesting to know what safeguards are in place to ensure that unwitting members of the public, who are thinking of seeking chiropractic treatment, aren’t ensnared by that quackery.

    David wrote:

    …it should be remembered that spinal manipulation isn’t any more effective than cheaper, more convenient, and safer options…

    As has been stated ad nauseam, chiropractic involves much more than manipulation.

    It has also been stated ad nauseam that anything other than spinal manipulation (or rather, specific spinal adjustments) isn’t real chiropractic – it’s physiotherapy, and, as we know, less than half of all UK chiropractors limited their interventions to that type of practice.

    David wrote:

    Commonsense would demand that [factual and accurate] information be sought from a source other than chiropractors, most of whom earn their livings in private practice.

    Commonsense would demand that factual and accurate information regarding orthopaedic surgery should be sought from orthopaedic surgeons. That factual and accurate information regarding dentistry should be sought from dentists. That factual and accurate information regarding veterinary practice should be sought from vets. That fctual and accurate information regarding chemotherapy should be sought from an oncologist.

    That might be so, but you can almost guarantee that the basis for their interventions *aren’t* based on quackery. Unfortunately, the same cannot be said for chiropractic.

    David wrote:

    Of course, Blue Wode would like you to believe that chiropractors do their work only for the money but there again you would expect that from him. We have of course been here before when Blue Wode has made bald allegations of dishonesty, but has not produced the evidence to back it up. In case readers aren’t aware, on 30th June Blue Wode wrote:

    I am for freedom of informed choice.

    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.

    My respoonse was:

    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.

    Of course we never have had the evidence.

    As far as financial interests go, I’ve pointed out before that a former Chairman of the GCC said the following…

    “In spite of strong mutual suspicion and distrust, the profession united under a group formed specifically to pursue regulation and secured the Chiropractors Act (1994)…..Regulation for a new profession will literally ‘legitimise it’, establishing its members within the community, making them feel more valued. In turn, this brings greater opportunity for more clients and a healthier bank balance.”
    http://tinyurl.com/323whhk

    With regard to your “straight-forward accusation of dishonesty” claim about my previous comments, 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. Indeed, I hope you recall that psychologist, Andrew Gilbey, analysed my comments further on in that discussion:

    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 committing 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!

    Quite.

  20. So much hot air, so little time…

    So, are you saying that my succinctly put support for James Jones is unwarranted, that his claims are incorrect, and that he hasn’t rattled you and Stefaan with his ability to through all the chiropractic bluster and to express, very well IMO, what he sees?

    @Blue Wode: For once I shall agree with these conclusions at the address of David…

    Congratulations on hitting a nerve or two with the practicing chiropractors commenting here.

    Nicely put (nerve-chiropractic-hilarity ensues) but no, I just enjoy the discussion and the developments, no nerves were harmed during the reading of James Jones’ post.
    Thing is BW, IF you are indeed what you claim to be (my interpretation) “a per-suer of truth and fairness to all” then are you not being a tad unfair and untrue to chiropractic? You may have a point towards certain chiropractors or even a small portion of the chiropractic profession, but your claims and comments do not in any way relate to chiropractic, only to some practitioners who can call themselves chiropractors. True, chiropractic can be practised in better ways than it sometimes is,… consent, claims made, advertising, cost etc. but, and this is where I think you are being unfair, this is true for all professionals, let alone healthcare professionals. It may be that I am only seeing the part of you that deals with chiropractor-induced unfairness because I don’t tend to look at blogs about GP’s (although there is one but that is just to read what Ernst is up to), lawyers or dentists. And maybe you have the voice the same grievances there, in which case; fair does.
    If not then;

    That might be so, but you can almost guarantee that the basis for their interventions *aren’t* based on quackery. Unfortunately, the same cannot be said for chiropractic.

    Who can almost guarantee that? And who says that chiropractic interventions are based on quackery? Surely we can agree that the “intervention” is one thing, the claim made in regards to the powers of that intervention a completely other thing? Low amplitude, high velocity manipulative techniques (the “intervention” you seem to have most of a bee in your bonnet about) are being adopted left right and centre as a method to retrain movement patterns but only very few people seem to be grasping the important difference between doing that in order to mobilise the joint and doing that to retrain the movement pattern. Physiotherapeutic approaches (by the way that was my first line of training-so thank you for the “young practising chiropractor” statement do it for the former reason, chiropractors (should) do it for the latter… you see, that’s philosophy for you. So, just for clarity sake, you’re not upset about chiropractors helping people because they manipulate vertebral joints (for readers that is “amongst others”), you’re not upset about the philosophical context in which they practice that (after all who could disagree that trying to affect (possibly in a flash of delusion) cause where necessary or viable is a good idea?) but you are upset about certain chiropractors not explaining risks well enough and making claims for which there is no or too little good quality evidence… did I get that right?
    If I did, could you then please consider moderating the generalisations? Zeno is doing tons of legwork on the issue of claims, for which my fullest support… so maybe you could go and stand outside chiropractic offices and ask people whether we discussed risk with them? Problem is of course that the evidence in regards to risk is indeed very low and very poor (albeit repeatedly requoted by Ernst) and in comparison to medical procedures negligeable. You see, most of us work very hard and diligently, have worked hard for our degrees and titles, make lots of people lots better at a price they themselves are willing to fund whilst happily making them aware of potential (however small and unproven) risks and lack of RCT-evidence for any improvements to result. To the clinician, the ones who have patients in front of them, that is all that will ever really matter. And unfortunately for your campaign, it is also all that will ever really matter to the patient.
    Zeno’s campaign on the other hand is different, it actually focuses chiropractors back to their original philosophy (don’t treat the symptom, treat the person-no health benefit claim should be made) and is doing us a huge favour, because after this refocusing we will go and do some research and we will find what we find and keep doing what we should always have been doing: making people better.
    Kind regards,
    Stefaan
    This is only the beginning

  21. ps.
    @Blue Wode

    Nevertheless, is it ethical that chiropractors should be extracting a fee for treating otitis in children when the current evidence does not support it as an intervention?

    Is it ethical for chiropractors NOT to treat the crying, suffering child, when he knows there might be an intervention his/her experience has shown could help THIS particular child (rather than “any child with otitis media”) because the child displays a problem they know may be related JUST because there is no RCT evidence to support it?
    This is the clinical dilemma. The patient’s dilemma is that of weighing up the odds and making a decision to pay for it (which is a non-issue really as we can no guarantee results, and people can get their money back if they didn’t get better as promised). Unless you are of course suggesting that you are wiser than the patient and they shouldn’t be left to make that decision.
    Stefaan

  22. Blue Wode wrote:

    …I won’t be feeding you any longer.

    Classic Blue Wode. And the best example of hipocrisy I think I have ever read.

    Unable to engage in the debate, refusing to acknowledge that the facts refute his arguments and that he has mistakenly and/or deliberately misled the public, he then hides away behind yet another ad hominem attack.

    It really is staggering that this character puts himself forward (although never having the guts to identify himself) as offering an objective view of chiropractic.

    Readers beware!

  23. @BW that’s a shame, just strange that you should feel it wrong for me to enjoy the discussion whilst focusing on progress and not feel that my nerves were hit by the James Jones’ comment (that was after all the context in which that comment was made). I obviously mistook your comment to be of a constructive and caring nature. I didn’t think it was essential to good debate to not enjoy it but instead one should be hurt by it and emotionally swayed or deterred for it.
    So long old pal
    Stefaan
    This is only the beginning

  24. @stefaan

    You say, “Is it ethical for chiropractors NOT to treat the crying, suffering child, when he knows there might be an intervention his/her experience has shown could help THIS particular child (rather than “any child with otitis media”) because the child displays a problem they know may be related JUST because there is no RCT evidence to support it?”

    Interesting idea, but about as bad science/naive as it can get. The main problem centres around the premise “…when he knows… “. Quite simply, he doesn’t know.

    Stefaan – even if Blue Wode won’t feed you anymore, I’ll try (although I realise it will only be tidbits in comparison to the banquet that Blue Wode offers you). Why? Becuase I genuinely think that your posts help the cause! 😉

  25. @Andrew Gilbey
    I think the word you’re looking for is empirical evidence.
    Empirical evidence may or may not stand up to the RCT test, but conclusions can only be drawn from the test if it in fact assesses the parameters under scrutiny (the hypothesis) and the conclusion can only reflect the conclusion of the hypothesis and not be extended to mean any more than that.
    Studies in regard to colic, otitis media, in fact pretty much any study ever done in regard to the hypothetical health benefits (in my opinion including those relating to back pain by the way) of chiropractic care do not reflect the chiropractic hypothesis.
    So, “bad science” or not is really down to whether or not you accept the limitations of RCT’s in that they show with high levels of reliability whether the hypothesis is or is not statistically true. If you do accept that, then you’ll appreciate that the inclusion of the bold words in my statement make it impossible for you to negate the validity of experiential and empirical evidence as being the source of “best available evidence” for that particular scenario I stated.
    Therefore his/her (the chiropractor) experience IS best evidence and whilst it is healthy and accurate to critique that for being weak and unreliable, it still is best evidence, leaving the question to remain the same: would it be ethical for the clinician NOT to act when best evidence shows there might be evidence to support it just because the level of evidence is not RCT-grade?
    Bad science? Or just seeing the world for what it is and is not?
    The fetishification of RCT’s is sometimes obscene and often disrespectful of the patient choice and the clinician’s experience and whilst I fully support its value, I take it for what it is.
    Kind regards,
    Stefaan

  26. @Stefaan

    Interesting argument, but not all evidence is equal (I recollect Zeno and/or BW have gone into this issue in much more detail in earlier posts). I agree that chiropractor experience is evidence, but it’s very seldom going to be the best evidence available. (I’d be fascinated to see if there is any instance where it is.) Arguing otherwise suggests you simply don’t understand the logic of science and enquiry.

  27. Andrew. Your comments are interesting, but irrelevant. You cannot stand on your high horse and talk about evidence when one looks at the past history of your dealings with the chiropractic profession in New Zealand.
    In New Zealand the Health Practitioners Disciplinary tribunal accepts chiropractic evidence, as does the Accident Compensation Corporation and the Health and Disabilities Commissioner. All these are government departments or judicial entities.

    There have been in excess of four complaints made by you to the New Zealand Advertising Standards Authority, these have been essentially thrown out. I suggest the readers of this blog go to the following sites and read the decisions.

    http://www.asa.co.nz/decisions.php?year=2010 decision 10/290
    http://www.asa.co.nz/decisions.php?year=2009 decisions 09/120, 09/210, 09/243

    The NZ ASA accepted chiropractors evidence in preference to yours.

    Your most recent letter to the editor of the New Zealand Medical Journal
    Chiropractic claims in the English-speaking world
    Edzard Ernst, Andrew Gilbey
    09-Apr-2010 – Vol 123 No 1312
    Was so poorly written and illogical that the reply absolutely decimated the content of your letter.

    A response to the letter “Backlash follows chiropractors’ attempts to suppress scientific debate”
    James Burt, David Owen; on behalf of the New Zealand Chiropractors’ Association
    16-Jul-2010 – Vol 123 No 1318

    I suggest the readers of this blog judge for themselves you ability to cogently comment on the chiropractic profession.

  28. I took your advice Glibley Glibley and followed those links to the New Zealand ASA decisions.

    The first one (10/290) was thrown out, not because the chiro provided robust evidence for the claims about colic he was making, but because the ASA decided the website was an editorial, not an advertisement, and was therefore not within its jurisdiction.

    The second one (09/120) was about the abuse of the title Dr and nothing to do with the paucity of evidence for chiropractic.

    The third is about the HPV vaccine and nothing to do with chiropractic. It wasn’t even a complaint by Andrew Gilbey.

    In 09/243, the chiro removed misleading statements from his website!

    How exactly did you think these ASA cases undermine Andrew Gilbey?

  29. @Andrew Gilbey

    I agree that chiropractor experience is evidence, but it’s very seldom going to be the best evidence available. (I’d be fascinated to see if there is any instance where it is.)

    I would be fascinated to see where it isn’t…isn’t that ironic?
    Like I have said before: there simply ISN’T any RCT-level research that has tested the chiropractic hypothesis. In case reiteration is helpful: “manipulation” for “a symptom” IS NOT the chiropractic hypothesis.
    That the ASA needs RCT-level support for claims to be made is one thing. A wise decision, protecting the world of random nonsense. But we are not discussing the ASA’s decision to set the bar that high, we are discussing whether it would be ethical for the chiropractor to NOT act as per the best available evidence (which as stated often (and definitely in the case under discussion) will be their own experience…
    Regards,
    Stefaan Vossen

  30. Hey, Blue Wode, you should try to catch Dara O’Briain’s current show. Saw him at the Apollo tonight. He raised the roof with his cracks (no pun intended) about chiropractors. I think you’d enjoy it. ;-).

  31. Glibley Glibley said:

    Oops
    http://www.asa.co.nz/display.php?ascb_number=09211
    is the correct listing.

    Still nothing to do with the paucity of robust evidence for chiropractic, just a ruling that the ASA didn’t think using the title Dr was misleading. The advertiser did change his website as a result, though.

    I would be interested if there are other complaints and how the NZ ASA has handled them.

    They are all there for everyone to see…

    What do you think it is in the New Zealand Medical Journal article that precludes Andrew Gilbey from cogently commenting on the chiropractic ‘profession’?

  32. Zeno.
    Read the letters of complaint that Andrew Gilbey wrote. Statements like,
    “As far as I am aware, Chiropractic has nothing to do with neurology”,
    show a complete absence of understanding of neuro-musculo-skeletal medicine, of which chiropractors are just one of the groups of practitioners.

    As far as the NZMJ article are concerned, the letter from Holt (not Ernst)and Gilbey shows an example of cherry picked evidence that has been discussed ad nauseum and discredited repeatedly.

    The reply by Owens and Burt says,

    “The letter attempts to position the chiropractic profession as “anti-science” and then presents the results of an “informal analysis of current material”. The ‘overwhelming consensus’ Gilbey and Holt refer to is indeed present on skeptic blogsites. However, the portrayal of chiropractic as cultist, unscientific, and having a philosophy incompatible with modern medicine selectively ignores the findings of many independent government enquiries5–8 and the World Health Organization9 which have recommended the use of chiropractic care in selected circumstances. It also contradicts the opinions of many independent agencies, including the American College of Surgeons10 along with findings published in the journal of the American Academy of Family Physicians that encouraged family physicians to positively “re-evaluate their relationship with chiropractors”.

    The New Zealand Commission of Inquiry into Chiropractic also accepted the evidence of chiropractors in preference to medical practitioners. Davis Katz, the medical “expert” was totally discredited (he lied) as was Stephen Barret’s organization. The evidence of the chiropractor, neuro-physiologist and medical practitioner, Scott Haldeman (PhD) was preferred to Katz as was the evidence of chiropractic radiologist Terry Yochum. (Just to give Andrew Gilbey an example of chiropractors evidence being preferred).

  33. Gibley Gibley wrote:

    “Andrew. Your comments are interesting, but irrelevant. You cannot stand on your high horse and talk about evidence when one looks at the past history of your dealings with the chiropractic profession in New Zealand.

    -snip-

    Your most recent letter to the editor of the New Zealand Medical Journal
    Chiropractic claims in the English-speaking world
    Edzard Ernst, Andrew Gilbey
    09-Apr-2010 – Vol 123 No 1312
    Was so poorly written and illogical that the reply absolutely decimated the content of your letter.

    A response to the letter “Backlash follows chiropractors’ attempts to suppress scientific debate”
    James Burt, David Owen; on behalf of the New Zealand Chiropractors’ Association
    16-Jul-2010 – Vol 123 No 1318

    I suggest the readers of this blog judge for themselves you ability to cogently comment on the chiropractic profession.”

    Gib, I don’t think I’ll be the only one who finds your comments above less than articulate. Nevertheless, I would like to make a few points about the issues you appear to have raised. Firstly, for the benefit of interested readers, this is the link to the paper you cite, Chiropractic claims in the English-speaking world, Edzard Ernst, Andrew Gilbey, New Zealand Medical Journal, 09 April 2010 – Vol 123 No 1312:
    http://www.dcscience.net/Ernst-Gilbey-Chiropractic-claims-NZMJ.pdf

    I’m not sure what it has to do with Andrew Gilbey’s most recent (co-authored) letter to the editor of the New Zealand Medical Journal. Perhaps you would care to elaborate?

    Secondly, I’ve read through the letter, “Backlash follows chiropractors’ attempts to suppress scientific debate” by Shaun Holt and Andrew Gilbey, New Zealand Medical Journal, 11 June 2010, Vol 123 No1316, and the response to the letter, “Backlash follows chiropractors’ attempts to suppress scientific debate” by James Burt and David Owen; on behalf of the New Zealand Chiropractors’ Association, New Zealand Medical Journal, 16 July 2010 Vol 123 No 1318, and the latter does not impress.

    From the Holt and Gilbey letter:

    The recent failure of the British Chiropractic Association’s attempt to sue the science writer Simon Singh for defamation1 has resulted in a number of important developments in terms of academic free speech and, almost certainly, the standing of the chiropractic profession.

    This failed legal action followed similar actions in New Zealand whereby the New Zealand Medical Journal faced legal threats after publishing a paper about chiropractors [ http://www.dcscience.net/?p=245 ] and a formal complaint was made to the Broadcasting Standards Association after comments made on television by one of the authors of this letter.
    [ http://www.bsa.govt.nz/decisions/2009/2009-058.html ]

    -snip-

    Somewhat ironically, the BCA’s case against Singh appears to have triggered a backlash against the chiropractic profession’s attempt to suppress scientific debate, resulting in their practices and claims being scrutinized by academics, health professionals, journalists and, not least, bloggers. The overwhelming consensus appears to be that there is a dearth of evidence to support many of the claims made by chiropractors, which are mostly based upon a highly dubious anti-science rationale.

    We conducted an informal analysis of current material that is critical about chiropractic practices and noted criticism based upon the following themes:

    1. Stifling free speech
    2. Unsupported claims that they can treat non-musculoskeletal diseases such as asthma, ear infections, colic etc
    3. Treating children
    4. Dangerous advice and quackery, such as advice not to vaccinate children
    5. Use of the title “Doctor”
    6. Concerns there is a causal link between neck manipulation and stroke
    7. Biological implausibility of treating non-musculoskeletal disease by manipulating the spine
    8. Overuse of X-rays

    An evidence-based approach to medicine means that chiropractors, doctors and any other practitioners who offer to treat patients should have their claims and practices questioned to make sure that they are safe and effective.

    In response to the Holt and Gilbey letter, Burt and Own said:

    The New Zealand Chiropractors’ Association (NZCA) would like to address a number of inaccuracies in the letter “Backlash follows chiropractors’ attempts to suppress scientific debate”.

    The authors infer that the NZCA complaint made to the “Broadcasting Standards Association” (sic) about comments made on television regarding chiropractic by Shaun Holt was somehow an attempt to stifle academic free speech and suppress scientific debate. This is incorrect. The complaint was primarily directed at a number of statements Holt presented as facts, but which were inaccurate. The complaint focused on the following statements, with relevant extracts of the Broadcasting Standards Authority’s ruling provided:

    Statement that chiropractic treatment “can cause stroke” and has resulted in “at least 700 cases” of severe injury

    [52] In the Authority’s view, the information supplied to it by Dr Holt (see paragraphs [29] and [30]) does not provide sufficient basis for his statement that chiropractic treatment “can cause stroke”.

    [56] …It therefore finds that it was also inaccurate to state that there are over 700 cases of such injuries, and that viewers would have been misled by the statement.

    At the time of broadcast the Bone and Joint Decade had already published the most comprehensive research into vertebrobasilar artery (VBA) stroke, looking at over 100 million person years worth of data. They uncovered only 818 cases of all aetiologies and “no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care”. The incidence of VBA stroke was higher in both chiropractic and primary healthcare provider groups compared to age and sex matched controls, and this was considered likely due to patients with headache and neck pain from a VBA dissection in progress seeking care before their stroke. Regardless, this is an extremely rare condition with risk factors that may include yoga, painting ceilings and nose blowing.

    The reference to ‘at least 700 cases” is not based on research published in any peer reviewed literature.

    It’s really very disappointing to see such reckless spin coming from two healthcare professionals, particularly when a recent, responsible analysis of the Cassidy et al study, which they cite above, arrived at the following conclusions:

    “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

    Burt and Owen continue…

    The letter attempts to position the chiropractic profession as “anti-science” and then presents the results of an “informal analysis of current material”. The ‘overwhelming consensus’ Gilbey and Holt refer to is indeed present on skeptic blogsites. However, the portrayal of chiropractic as cultist, unscientific, and having a philosophy incompatible with modern medicine selectively ignores the findings of many independent government enquiries5–8 and the World Health Organization which have recommended the use of chiropractic care in selected circumstances. It also contradicts the opinions of many independent agencies, including the American College of Surgeons10 along with findings published in the journal of the American Academy of Family Physicians that encouraged family physicians to positively “reevaluate their relationship with chiropractors”. In light of this the NZCA would ask readers that they question these aspects of Gilbey and Holt’s letter on chiropractic published in the New Zealand Medical Journa.

    The NZCA defends the right to free speech but does not consider the spread of inaccuracies, innuendo or the selective presentation of research under the guise of academic debate to be valid.

    Holt and Gilbey’s assertions are hardly inaccuracies. In 2003, 69% of all UK chiropractors felt confident to treat visceral/organic conditions, and currently this figure stands at 74%. In the US,nearly 80% of chiropractors teach a relationship between (the fictitious) subluxation and internal health, with 88% believing that subluxation contributes to over 60% of all visceral ailments, and 90% feeling that chiropractic treatments should not be limited to musculoskeletal conditions.

    Are chiropractors in New Zealand likely to be any different?

    Prove me wrong.

  34. Glibley Glibley said:

    As far as the NZMJ article are concerned, the letter from Holt (not Ernst)and Gilbey shows an example of cherry picked evidence that has been discussed ad nauseum and discredited repeatedly.

    Sorry, my irony meter just exploded.

    However, I’ll try to find time to read the letters tomorrow.

  35. Andrew Gilbey said

    “Interesting argument, but not all evidence is equal (I recollect Zeno and/or BW have gone into this issue in much more detail in earlier posts). I agree that chiropractor experience is evidence, but it’s very seldom going to be the best evidence available. (I’d be fascinated to see if there is any instance where it is.) Arguing otherwise suggests you simply don’t understand the logic of science and enquiry.”

    I have given you several examples of where chiropractic evidence surpasses anyone else s, e.g. Haldemans evidence was preferred against Katz and the NZ Commission of Inquiry.

    I am pleased you have published the Broadcasting Standards Authority judgment.
    Holt had to provide the evidence for the “700 stokes” comment.

    The BSA said

    “The complaint was primarily directed at a number of statements Holt presented as facts, but which were inaccurate. The complaint focused on the following statements, with relevant extracts of the Broadcasting Standards Authority’s ruling provided:

    Statement that chiropractic treatment “can cause stroke” and has resulted in “at least 700 cases” of severe injury

    [52] In the Authority’s view, the information supplied to it by Dr Holt (see paragraphs [29] and [30]) does not provide sufficient basis for his statement that chiropractic treatment “can cause stroke”.

    [56] …It therefore finds that it was also inaccurate to state that there are over 700 cases of such injuries, and that viewers would have been misled by the statement.”

    The BSA found these statements to be inaccurate, even after being provided with the “evidence” by Holt and no doubt Ernst.
    It is time that Blue Wode provided us with the evidence for that “700” figure, because Holt could not.

    “The reference to ‘at least 700 cases” is not based on research published in any peer reviewed literature”, according to the BSA.

    The aim of my writing in this blog is not to “impress” you. It is to provide examples of inaccuracies in statements by yourself and BW, that you assume are correct, but under investigation, have proven to be untrue. The 700 stroke cases is a perfect example.

    As an aside, recent research has shown that if a patient is to take the Non Steroidal Anti-Inflammatory Diclofenac, it will increase the risk of a stroke (or MIA) by up to 85%. Brufen by 35%. In discussing to incidence of strokes and the possible co-relation to spinal manual therapy, it would be responsible to look at co-morbidities that exist and also medication that the patient is taking at the time. A significant number of patients receiving spinal manual therapy from chiropractors, osteopaths, physiotherapists and medical practitioners are taking NSAIDS.
    These could be a significant contributing factor to any side effects from the treatment received.

  36. Gibley Gibley wrote:

    It is time that Blue Wode provided us with the evidence for that “700″ figure, because Holt could not.

    If you scroll down to the May 2004 news item in the following link, you will find dozens of reports (possibly hundreds – I haven’t counted them), of adverse events associated with neck manipulation:
    http://web.archive.org/web/20080406151720/www.chirovictims.org.uk/victims/news.html

    In the following link you can find more reasons to justify why the cautionary principle should be applied when thinking about using neck manipulation as an intervention, not least in view of the fact that other effective options exist, e.g. exercise therapy or massage, which have not been associated with significant risks:

    Deaths after chiropractic: a review of published cases
    Ernst, E. Int J Clin Pract. 2010 Jul;64(8):1162-5.
    http://www.ncbi.nlm.nih.gov/pubmed/20642715?dopt=Abstract

  37. @BW:
    if you go onto youtube you will find hundreds, nay thousands of reports of strange lights associated to extra-terrestrial life…
    The link with “reports” you refer to does not in any way constitute “robust” evidence of any causal link between neck manipulation and stroke. I think we can put that one to bed easily, can’t we? This is as “robust” as the available evidence to support chiropractic claims for otitis media…
    Trying to protect the programme and/or the articles in the assertion that these constitute robust evidence is either foolish/as ridiculous as chiropractors making those as advertised claims or symptomatic of a point of view that in this particular case low-level evidence is warranted (the liberal use of the “cautionary principle” you refer to would put you in the latter group).
    The application of the cautionary principle has already been discussed with (amongst others) Edzard (see Pulse Today) and on chiropracticlive and HAS to be done IN THE LIGHT OF risks and benefits of alternatives for the SAME situation for the principle to be valid.
    The fact that you apply the principle so liberally and in an indiscriminate fashion is either symptomatic of bias or lack of understanding of what the “same situation” constitutes. The fact that you refer to exercise therapy or massage as “other effective options” indicates that you again belong to the latter.
    Indeed, the notion that as chiropractors we would treat those patients who would respond well to these options, means that you have still not understood what the chiropractic theory really is.
    I can understand why, as it does constitute one of the finer points of chiropractic theory, and it is often missed by chiropractors, some of whom you use as references… You are welcome to criticise individual chiropractors, for all I care, but your assertions do not extend to chiropractic, hence why my previous calls at your address to moderation in the width and breadth of your generalisations, as they are foolish and symptomatic of shallow knowledge on the topic.
    Despite the fact I have stated this before, I will reiterate the point: if there is no “Subluxation” (I am using the term just to wind you up, but I mean it in the understanding of “a cause of dysfunctional movement pattern”), the chiropractor hasn’t got a job… and a Subluxation is an interference on Innate Intelligence’s ability to heal the body (again, to wind you up; it is not something you need to “believe” in, it is what healed your scabs and broken ulna up when you fell of your bike when you were 5, got rid of your cold last winter, and makes the physiological parameters of your kidneys change when you are chronically dehydrated. When exercise therapy or massage would work then it follows that there was no Subluxation, as massage and exercise do not remove Subluxations. The problem you have there is what does “would work” represent? For how long? To what degree? Finding and defining Subluxations is as difficult as answering those questions.
    Massage is great to relieve shoulder pain, but IF it always comes back after two days of massage then maybe looking at that person’s bite or neck function would be well-advised don’t you think? This is one where nuance, definition and refinement are no luxury.
    Finally, it would be idiotic of me to suggest that all chiropractors would, as a matter of principle, refuse to treat someone who would possibly respond to those treatments you suggest. It does however remain, as ever, the individual patient’s choice whether to embark on treatment which may not strictly speaking be the only option, nor maybe the safest, but the one the patient chooses for whatever reason (speed of recovery, trust in the clinician, ease of access, etc.). The only point where ethics really come into the equation is when a patient is wanting to receive treatment even though the treatment does not carry any potential benefit… and you’ll have some trouble proving that one, cue the debate surrounding plastic surgery. The fact that the risks involved in chiropractic care are infintisimally lower than those surrounding plastic surgery, makes the debate surrounding the ethics of agreeing to treat a patient who may benefit from less invasive treatment (but chooses the chiropractic option regardless) more irrelevant in directly proportionate measure.

    So, in conclusion; whether the ethical considerations you and Andrew Gilbey give to patients choosing chiropractic care upsets you or not, that, by itself is very, very irrelevant, both in consideration of individual patient choice and its ethical relevance in absolute. That you may think that patients are not well informed of risks and benefits is something you will have to take up with individual chiropractors, not with Chiropractic. That chiropractic has in your view no place in the healthcare spectrum, tells me you don’t know the healthcare spectrum and/or the part chiropractic plays in it, which is no shame, just a basic black hole in your argument.
    Either way, there’s not that much going for your (and Edzard’s) argument because it is fundamentally and repeatedly flawed in places where it really shouldn’t be to be taken seriously.

    ps you’ll need to do some homework on somato-visceral reflexes if you want to understand why spinal events can sometimes have an effect on organs… and you’ll definitely need to do some homework on it if you want to criticise the notion.

    @Andrew Gilbey;
    I really would love to see an example where chiropractor’s experience is NOT best available evidence. Let me know what you’re thinking.

    Kind regards,
    Stefaan Vossen
    This is just the beginning

  38. Blue Wode references Edzard Ernst latest writings:

    Deaths after chiropractic: a review of published cases
    Ernst, E. Int J Clin Pract. 2010 Jul;64(8):1162-5.
    http://www.ncbi.nlm.nih.gov/pubmed/20642715?dopt=Abstract

    This is a perfect example of Ernst’s MO and the title gives away all you need to know. “Deaths after chiropractic”.

    Ernst knows perfectly well that there is no evidence that chiropractic treatment has ever caused a death, and you can bet your bottom dollar that if there was any such evidence he would be letting you know about it. The cases he uses to cast such a negative light on chiropractic can only be related in terms of timescale, not cause.

    This is the letter the American Chiropractic Association wrote in response to the article being repeated on the WebMed website:

    Dear Ms. Wiebe,

    Doctors of chiropractic were surprised and very disappointed to see Medscape
    highlight what we believe is a flawed and sensationalistic paper on the
    appropriateness of chiropractic manipulation by Edzard Ernst in its Sept. 7
    editions of *Orthopaedics MedPulse *and *Family Medicine MedPulse*. A review
    of the paucity and anecdotal nature of the data on which Ernst bases his
    conclusions should have given Medscape pause; further examination would have
    revealed that Ernst omitted mention of the most credible scientific
    literature on the effectiveness and safety of chiropractic manipulation.
    This raises serious questions about not only Ernst’s conclusions but also
    his objectivity relative to chiropractic care.

    We thank you for understanding our concerns, and we accept your offer to
    submit an article about chiropractic care to Medscape that will give your
    readers more balanced information.

    We do understand that Medscape has partnerships with dozens of journals and
    that you select content with the understanding that they have vetted their
    content carefully; however, the Ernst paper clearly did not undergo rigorous
    review. For example, as your readers know, causation cannot be established
    by case reports alone, yet Ernst makes seriously unsupported assertions
    about the safety of chiropractic treatment using only case reports. This is
    unscientific and irresponsible at best.

    There is significant support for the appropriateness of manipulation in the
    scientific literature, far too much for Ernst to state that ‘there is no
    good evidence for assuming that neck manipulation is an effective therapy
    for any medical condition?’ which he supports with one reference of his
    own, or that the risk outweighs the benefit. There are many systematic
    reviews conducted by multidisciplinary teams who have documented clinical
    effectiveness of spinal manipulation. (1-9) One example is the systematic
    review released in 2001 from McCrory and Penzion et al. at the respected
    Duke University Evidence-Based Practice Center in Durham, NC, which found
    that spinal manipulation was safe, effective and appropriate for patients
    with common forms of primary headache with a cervical spine component and
    offered a valuable alternative to patients concerned about the side effects
    of continued use of medications. (10)

    Ernst also failed to mention the recent major research from Cassidy, et al.
    (11) concluding that there is no greater risk of vertebrobasilar artery
    stroke following chiropractic cervical manipulation than there is following
    visits to a primary care medical physician. The study analyzed nine years’
    worth of data amounting to 110-million person years. It suggests that in
    very rare cases there are patients with a stroke in progress who seek
    chiropractic or medical care for neck pain, the first symptom. The stroke
    then follows the chiropractic or medical intervention but is not caused by
    it.

    If Ernst was truly interested in examining the safety and effectiveness of
    spinal manipulation, he would have referenced the studies cited in this
    letter. If he was truly interested in public health, he would have discussed
    the risks of spinal manipulation, not *chiropractic *manipulation. In the
    United States and internationally, spinal manipulation is also performed by
    doctors of medicine and osteopathy and by physical therapists.

    As many of your readers know, doctors of chiropractic today often work
    closely with medical doctors and other health care practitioners, and it is
    this spirit of cooperation that patients want and deserve. As such, we
    greatly appreciate the opportunity to share what we know about how
    chiropractic has become integrated into U.S. health care and to bring more
    balanced studies about the safety and efficacy of chiropractic care to your
    readers’ attention.

    Sincerely,
    Rick McMichael, DC
    President – American Chiropractic Association

    1. Oliphant D. Safety of spinal manipulation in the treatment of lumbar disk
    herniations: a systematic review and risk assessment. J Manipulative Physiol
    Ther. 2004 Mar-Apr;27(3):197-210.
    2. Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadrado ML, Pareja JA. Spinal
    manipulative therapy in the management of cervicogenic headache. Headache.
    2005 Oct;45(9):1260-3.
    3. Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low
    back pain: a review of the evidence for an American Pain Society/American
    College of Physicians clinical practice guideline. Ann Intern Med. 2007 Oct
    2;147(7):492-504.
    4. Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW. Chiropractic care for
    nonmusculoskeletal conditions: a systematic review with implications for
    whole systems research. J Altern Complement Med. 2007 Jun;13(5):491-512.
    5. Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S. Evidence-informed
    management of chronic low back pain with spinal manipulation and
    mobilization. Spine J. 2008 Jan-Feb;8(1):213-25.
    6. Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J,
    et al. Treatment of neck pain: noninvasive interventions: results of the
    Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated
    Disorders. Spine. 2008 Feb 15;33(4 Suppl):S123-52.
    7. Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of
    manual therapies: the UK evidence report. Chiropr Osteopat. 2010;18:3.
    8. Gross A, Miller J, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, et al.
    Manipulation or mobilization for neck pain: a Cochrane Review. Man Ther.
    2010 Aug;15(4):315-33.
    9. Miller J, Gross A, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, et al.
    Manual therapy and exercise for neck pain: a systematic review. Man Ther.
    2010 Aug;15(4):334-54.
    10. McCrory DC, Penzien DB, et al. Evidence Report: Behavioral and Physical
    Treatments for Tension-Type and Cervicogenic Headache. Des Moines, IA:
    Foundation for Chiropractic
    Education and Research, 2001. Product No. 2085.
    11. Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver FL, et al.
    Risk of vertebrobasilar stroke and chiropractic care: results of a
    population-based case-control and case-crossover study. Spine. 2008 Feb
    15;33(4 Suppl):S176-83.

  39. @David

    Quoted from the letter that Rick McMicahel, DC, President of the American Chiropractic Assoociation, sent to the WebMed website:

    Ernst also failed to mention the recent major research from Cassidy, et al. (11) concluding that there is no greater risk of vertebrobasilar artery stroke following chiropractic cervical manipulation than there is following visits to a primary care medical physician. The study analyzed nine years’ worth of data amounting to 110-million person years. It suggests that in very rare cases there are patients with a stroke in progress who seek chiropractic or medical care for neck pain, the first symptom. The stroke then follows the chiropractic or medical intervention but is not caused by it.

    (11) Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver FL, et al.
    Risk of vertebrobasilar stroke and chiropractic care: results of a
    population-based case-control and case-crossover study. Spine. 2008 Feb 15;33(4 Suppl):S176-83.

    IMO, it is utterly unforgiveable of the ACA President not to mention that the Cassidy study says, on page S181, that:

    “…our results should be interpreted cautiously and placed into clinical perspective. We have not ruled out neck manipulation as a potential cause of VBA strokes.”

    Ernst even highlights that remark in his paper, to which I have already linked above:
    Ernst, E. Vascular accidents after chiropractic spinal manipulation: Myth or reality?, Perfusion 2010; 23:73-74
    http://tinyurl.com/37ejj22

    One can only hope that the Cassidy et al study in Spine, which formed part of a report by the Task Force on Neck Pain and its Associated Disorders, is thoroughly read through by the 16,000 neurologists to whom it was mass-mailed by the American Chiropractic Association:
    http://www.amerchiro.org/press_css.cfm?CID=2969

    Sadly, whether the neurologists read the study or not, it’s very unlikely that they will ever be made aware of the fierce criticism that the study’s lead author, David Cassidy, DC, came under from Sharon Mathiason, a mother whose 20-year-old daughter died following chiropractic neck manipulation for a tailbone injury:

    David Cassidy, before he was dismissed from the University of Saskatchewan, was called as an “expert” witness by the Chiropractic Association of Saskatchewan (CAS) at my daughter’s inquest.

    In the Globe and Mail article co-author David Cassidy is quoted “Has it ever happened that a chiropractor has caused a stroke? I can’t say it’s never happened. But if it’s happening, it’s not happening at a greater risk than when it is at a GP office”.

    Well guess what, chiropractor David Cassidy admitted on the stand into the death of my daughter they he had manipulated the neck of a woman and caused a stroke, a very severe one called Wallenberg’s syndrome. Did he say it never happened because this poor woman also saw her doctor in the past year? I doubt if he has ever seen a patient coming out of a doctor’s office having a stroke after a neck manipulation.

    More… (scroll down)
    http://www.chirowatch.com/Chiro-strokes/gm080120stroke.html

    The above can only serve to reinforce suspicions that a comment made recently on the internet is true: “Chiropractors are in the business of staying in business”. In other words, concede that subluxations are imaginary, and refrain from making all those unnecessary neck manipulations, and what are you left with? A market that is already saturated with other manual therapists who have built up good reputations largely free of quackery-related baggage.

  40. The tragic 26 deaths since 1926, that Ernst documents, pale into comparison to the 35000 Vioxx (anti-inflammatory) related deaths that occurred in the four years it was on the market. The causes of death were heart attacks, brought on by the weakening of the arterial walls as a side effect of Vioxx consumption.
    You do not address the likely possibility that these accidents could be the consequence of multi-factorial issues, such as the ingestion of Diclofenac at the same time as the spinal manual therapy (performed by chiropractors, physical therapists, osteopaths of medical practitioners). I can only presume, in this case, that you are not medically trained, to have missed this strong correlation, or have refused to recognize the causal link.
    Josef Stalin once said, “One death is a tragedy, 10,000 deaths is a statistic”.
    Blue Wode, you treat the 35,000 as a statistic. Shame on you.

  41. Gibley Gibley wrote:

    The tragic 26 deaths since 1926, that Ernst documents, pale into comparison to the 35000 Vioxx (anti-inflammatory) related deaths that occurred in the four years it was on the market. The causes of death were heart attacks, brought on by the weakening of the arterial walls as a side effect of Vioxx consumption.

    Are you seriously saying that the shortcomings of medicine excuse the maiming and killing of patients at the hands of chiropractors? If so, please read Death by Medicine:
    http://www.sciencebasedmedicine.org/?p=136

    Gibley Gibley wrote:

    You do not address the likely possibility that these accidents could be the consequence of multi-factorial issues, such as the ingestion of Diclofenac at the same time as the spinal manual therapy (performed by chiropractors, physical therapists, osteopaths of medical practitioners).

    Why, then, would a chiropractor want to exacerbate a potentially catastrophic situation by adding neck manipulation into the mix when it is already known that other effective options exist which are safer (and, in many cases, cheaper and more convenient)?

    Might I also point out a great irony in your comments. Currently in at least one American state, and in the UK, chiropractors are seeking prescribing rights…
    http://tinyurl.com/2wexz9m
    http://www.chiropracticlive.com/?p=391

  42. @BW
    you’re missing the point. Crucial to your rhetoric is whether or not manipulation as carried out by chiropractors carries a significant risk to strokes. In order to justify your wild claims you will have to back these claims up with relevant data. The data that are available, show that there might be a correlation between strokes occurring and people visiting clinicians involved in cervical manipulation and show the occurrence of such events to be no more significant as that of people visiting clinicians (and non-clinicians) who are not making use of these procedures.
    Ergo the crucial assertion to your claim is invalid.
    Thus you must reduce the width and breadth of your assertions and accept that it is invalid in the light of the available data.
    This, coincidentally, is the same logical error Edzard makes. Ernst has no data to his disposition to warrant the width and breadth of his claims either. This however does not stop him making these claims, however erroneous.
    As pointed out earlier his invocation of the precautionary principle is, like in the case of BW, erroneous in that it compares non-matching population groups and does not calculate into the equation risks of alternatives associated to the correct population groups. The precautionary principle is an important principle in the calculation of relative value of risk. Not comparing the correct population groups with each other invalidates the invocation of the precautionary principle. Classic bad science. In this particular case it is important to understand that the patients seen by chiropractors have often, if not almost always tried conventional therapies and failed to progress. This constitutes a clear definer of a separate and distinct sub-group of the neck-pain population. Unless of course BW and/or Edzard Ernst have good reason to believe that these population groups are NOT distinct in any relevant way.

    The irony of chiropractors seeking prescription rights is not lost on real chiropractors. Those who are indeed seeking these rights are breaking with fundamental definers of the chiropractic profession and as such do not represent the chiropractic profession. They have been termed medipractors, and have lost the correct sense of the population group they aim to serve as chiropractors.
    BW and Ernst are welcome to vent their dismay with medipractors but cannot make the basic mistake of assuming these to be chiropractors in any other than the legal sense.
    Such assumptions are symptomatic of poor understanding of their subject.
    Stefaan Vossen

  43. ps. The real risks associated to chiropractic care is that of manipulative therapies being applied to patients whose osseous integrity is compromised. The likelihood of this causing spinal cord trauma and/or paralysis is far greater than that of having the manipulative procedures being (causally or coincidentally-none knows) associated to stroke.
    This is why chiropractors have to be trained to such high levels. And guess what? Such, far more likely events, haven’t happened yet either… Aren’t chiropractors good at identifying when it is safe to treat? Aren’t they just!
    Stefaan
    This is only the beginning

    pps I introduce the consent process to the patient as the patient understanding that these procedures may maim and kill (no, seriously, I say this literally) particularly if I have missed something for which I could at the point of examination not establish any evidence. In case that I should have been able to establish such evidence they can sue me for negligence, otherwise they accept that as a clinician I cannot Doppler test, MRI scan, X-ray or refer for bloodtests every patient who comes in for treatment, just to be sure they have no cancer or other pathology.
    Guess what… I never had a patient walk out of my practice refusing to accept these terms and conditions. Patients are far more realistic and aware of real life than Blue Wode and Edzard Ernst seem to give them credit for.
    That is the difference between a statistic and a patient.
    Stefaan

  44. @Gibley Gibley (Friday 24 September 2010 at 09:25)

    Love the login name!

    You’re dead right regarding my complaints to the NZASA not getting anywhere. In hindsight, I have to admit they weren’t that strong – I wrote them late in the evening and didn’t make as strong a case as I should have. That said, one is now being appealed – so let’s see what eventuates there. Either way – follwing my lack of success I’m even more in awe of Zeno and Simon Perry’s letters of complaints. In my defense, I feel the NZASA is being a bit easier on the chiros than the UKASA.

    Now this is what will make some of you laugh – following the first three complaints to the NZASA, the chiropractic board complained about me direct to the university where I work. And direct to the vice chancellor! One of their complaints, in what I have to say was a rather long and rambling polemic, was that I was bringing the university into disrepute with my complaints. They also demanded to know the university’s position on chiropractic! I had to spend at least a day providing an answer to their complaint, when I should have been doing other things.

    The Ernst & Gilbey (2009) article that you refer to was a peer reviewed paper, rather than a letter. (Letters in the NZMA aren’t peer-reviewed, as such – just checked by the editor to ensure they’re not obviously mad.)

    There’s no need for me to comment on your other posts as BW and Zeno have already done so.

    However, if you are NZ based, can I ask if you have ever read a copy of the NZ report into chiropractic (1979)? (It’s available from any NZ library, as a loan from the national library.) Many chiropractors quote this report as evidence that chiropractic is safe, which, if you read the report, you will see is a warp-speed leap of logic. Of particular interest to me is that the report unequivocally recommends that chiropractors DO NOT use the title of doctor. When I have time, I intend to take this up with the relevant government minister, as the current NZ legislation (the HCPAA) seems to have failed to continue this recommendation explicitly.

  45. I have a question for chiropractors. Bearing in mind that the final sentence of Simon Singh’s article, ‘Beware the spinal trap’, concluded…

    “If spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.”

    http://tinyurl.com/32b57lg

    …why aren’t chiropractors allowing patients to play an active role in independently reporting any adverse events that they might experience? After all, chiropractors don’t always see their patients again, and it is known that complications don’t always present themselves immediately – e.g. strokes can happen days after vertebral arteries have been torn.

    I’ve been having a look at the UK chiropractors’ Chiropractic Patient Incident Reporting and Learning System (CPiRLS) http://www.cpirls.org/ and, unfortunately, it appears to be very secret – i.e. for chiropractors’ eyes only. Indeed, its reporting policy appears to be the exact opposite of the UK Medicines and Healthcare products Regulatory Agency’s (MHRA) which has a Yellow Card scheme which allows patients and the public to report suspected side effects of any medicine or herbal remedy, whether it was prescribed by a doctor or bought without a prescription: http://tinyurl.com/36pfa5y IMO, it seems rather odd that there’s not a similar provision made for chiropractic patients (or indeed CAM patients in general).

    Needless to say, the above concerns raise a very pertinent question: Can chiropractors be trusted to exclusively report patient adverse events? If what follows is anything to go by, the answer seems to be ‘no’.

    Not so long ago, Professor Edzard Ernst questioned the integrity of the methodology used in a (UK) prospective national survey into the safety of chiropractic manipulation of the cervical spine, and highlighted the very real problem of:

    “Having to rely on the honesty of participating therapists [chiropractors] who could have a very strong interest in generating a reassuring yet unreliable picture about the safety of their intervention.”

    In relation to that concern of Ernst’s, here’s something I observed:

    Interestingly, in their response, two of the survey’s authors, JE Bolton and HW Thiel [of the Anglo European Collge of Chiropractors], claimed that, in the UK alone, there were an estimated four million manipulations of the neck carried out by chiropractors each year. Yet, six months earlier, in October 2007, in a letter to the Journal of the Royal Society of Medicine, they claimed that the figure was “estimated to be well over two million cervical spine manipulations”. How that estimate could double in under 6 months is anyone’s guess, but it leaves them open to accusations that they may be trying to play down the risks. It’s also worth noting that in 2002, co-author, JE Bolton, seemed to have no qualms about recommending chiropractic as a placebo treatment for infants with colic in the apparent absence of published safety data.

    (That latter study does not consider the harmful aspects of chiropractic care that are far more common than the reported events. They include decreased use of immunisation due to misinformation given to parents, financial harm due to unnecessary treatment, and psychological harm related to unnecessary treatment and exposure to false chiropractic beliefs about “subluxations”. See: http://www.ncahf.org/digest07/07-14.html .)

    http://www.layscience.net/node/566

    In addition to that, a study which was published in 2008 revealed that the CPiRLS was being very much under-utilised: http://tinyurl.com/35qqcxp Its findings also indicated that the General Chiropractic Council’s recommendations on patient safety, which were made clear in Item 7 of the minutes of its 2nd March 2006 meeting, were not being fully met:

    If we are to provide a safe clinical experience for our patients then we need to put in place, within our clinics and within the profession as a whole, a reporting procedure, which allows for adverse events and near misses to be shared on an anonymised basis so that we can all learn from them.

    http://www.gcc-uk.org/files/link_file/C-020306-Open1.pdf

    It’s also worth noting that on page 42 of the General Chiropractic Council’s draft revalidation document (it can be found on its website), that of the 180 complaints that the British Chiropractic Council admitted to having received between January 2008 and September 2009, five of them were about treatment causing fractured ribs. (NB. Apparently the subluxation-based United Chiropractic Association and the Scottish Chiropractic Association didn’t bother to respond on the issue of complaints received.) Since there is no way of checking, one can only hope that those five injuries reported to the British Chiropractic Association will have been reported to the CPiRLS.

    In view of the above, and in the interests of patient safety, let’s have more transparency please.

  46. Andrew Gilbey
    Pleased you like the log in.

    The NZ Report Page 3 says,
    “The display of the title “Doctor” by a chiropractor who is not a registered medical practitioner should be strictly limited”.
    (Not forbidden)

    Your comment of….

    “Of particular interest to me is that the report unequivocally recommends that chiropractors DO NOT use the title of doctor”,

    is actually factually incorrect, as usual.

    David Colquhoun wrote about this issue in the 25 July 2008 issue of the New Zealand Medical Journal.

    This was the response of Karl Bale clarifies the issue, CEO of the NZ Chiropractic Board, published in the NZMJ, 22-August-2008, Vol 121 No 1280

    Use of the term ‘doctor”
    The article suggests widespread abuse of the title ‘doctor’ by chiropractors and others and uses the example of the Yellow Pages to emphasize this point. However, it should be noted that Chiropractors are permitted to use the title ‘doctor’ when this is suitably qualified to show that the title refers to their chiropractic role.
    In addition, chiropractors are listed in the Yellow Pages under the heading ‘Chiropractors’ and it is clear they are not holding themselves out to be registered medical practitioners.
    It should be noted that the Chiropractic Board is vigilant in its approach to the use of the title ‘doctor’ and publishes clear directions on the use of this terminology by members of the profession in its Code of Ethics and Standards of Practice as follows:
    The use of the title ‘Doctor’ must be qualified, for example, John Doe, Dr of Chiropractic or Dr John Doe, Chiropractor. Failure to qualify the use of the title ‘Doctor’ may contravene the provisions of the Medical Practitioners Act 1995 and he or she may be committing an offence under that Act.
    As an aside the Board notes that the protected title for medical doctors under the provisions of the Health Practitioners Competence Assurance Act (2003) is ‘medical practitioner’ not ‘doctor”.

    You belabor a point that has been discussed over and over again. Get over it!!

  47. @GG

    I’m not sure we are that different in our interpretation of what the report recommended. BAsically, the bottom line of the report is that there is no need for a chiropractor to adopt the title of doctor, irrespective of whether they qualify it (no pun intended).

    ANyway, even although chiropractors are under their own heading in the yellow pages, when they use the title of doctor, it could imply that they are (medical) doctors who practise chiropractic, rather than what they are: chiropractors who do not havea general medical qualification. More importantly, when I conducted the original research, I found a lot of chiropractors simply called themselves Dr Smith, with no mention of the fact it was an self-bestowed honorific and that really they were just chiropractors. I also found some other types of CAM providers did so, but chiropractors were by far the worst offenders.

  48. One gigantic yawn from Gibley Gibley to Andrew Gilbey.
    How tiresome.

    Andrew we have some very important issues here.
    1. You say that you did “original research”. Did you have Ethics Department approval for this “research”, or was is really just a poorly designed “survey”. If you did have Ethics Department approval of this research, from the university that employs you or any university, please provide evidence of it. As far as I am aware, when an academic is conducting research, prior approval from an Ethics Committee is required.
    2. There have been no complaints to the NZ Medical Council concerning patients being confused about who they are attending.
    3. I will wait with anticipation to your screams, when the physiotherapists start using the title “Doctor”. There is a “Doctor of Physiotherapy” degree being offered at Melbourne University in Australia. This is an under-graduate type degree offered to students with a previous degree, and it is not to the level of a PhD. (I admire you for having one). There are “Doctor of Physical Therapy” degrees available in the U.S. as under-graduate degrees. Same as D.O., M.D. and D.C. degrees.
    Your screams of anguish will be heard in the U.K.

    You have started to argue semantics rather than cogent points. If you really take that type of stand about the use of the title “doctor”, then you should also criticize dentists, osteopaths and vets (and soon physiotherapists) use already use that title.
    Have you laid complaints to any of their regulatory bodies?. If not, why not?
    If one needs a medical degree to call oneself “Doctor”, than I am sure all of your academic colleagues with PhD’s would disagree.
    If only those with a medical degree can call themselves “Doctor”, then you denigrate all the hard work academics have done to gain a PhD.
    So who can?, and who can’t? use the honorific title “Doctor”?

  49. So now one coroner’s opinion is “evidence” is it?
    You’re funny you are. Secondly the point is not that these things happen, whether or not connected to manipulative technique, nor is it even about whether or not some ER people think there is a correlation (read your own links about seeing patterns and the value of evidence for a change), it is about whether or not patients are told that there might be a risk. As you have been told before, ad nauseam I hasten to add, consent is far less of an issue these days, in the UK than you are making out. Lastly, look at the evidence file for Mr. Hoffman…. Now let’s see about that consent process….
    Stefaan Vossen

  50. @GG

    Point 1.

    You say, “As far as I am aware, when an academic is conducting research, prior approval from an Ethics Committee is required.”

    It depends upon the kind of research being conducted. (To be safe, I did seek out the opinion of the ethics chair.)

    Point 2

    Your point is irrelevant. Argumentum ad ignorantiam, maybe?

    Point 3

    Red herring – my concern relates to chiropractors (or other CAM providers) using the title of doctor.

  51. Andrew

    Ho hum, I do not think the topic is worth discussing anymore. I will let you get the last word in, simply because your obsession with the topic detracts from meaningful debate.
    Big Yawn.
    Best wishes.

  52. @Andrew Gilbey
    I am most fascinated about the interest you have in protecting the integrity and meaning of the title of Doctor, so I shall stick to that. You write in your last posting that it is of particular concern in relation to chiropractors or other CAM providers.
    Could you elaborate on this please? I am assuming that it is not a matter of principle when I say that I guess it is not because they are CAM providers, but rather that something you understand/perceive to be inherent to CAM providers that underpins your views. Could you identify and relate to me what the components are that contribute to this view? i.e. what is the understanding/perception you believe to be inherent to CAM providers that affords you the conclusion that they should not be able/allowed to call themselves “doctor”?
    Kind regards,
    Stefaan

  53. Following on from my comment above in which I linked to a Death Certificate that confirmed that a 39-year-old man had died as a result of chiropractic neck manipulation, readers might be interested to know that a new chiropractic stroke awareness organisation appeared:
    http://chiropracticstrokeawarenessorganization.com/

    Its section on informed consent is particularly interesting:

    Since there is no official reporting mechanism in place for strokes occurring after neck manipulations, and there is no mandatory informed consent standard for chiropractors, there is currently no way to accurately quantify the risk.

    http://tinyurl.com/29wgtfq

    However, that, apparently, only pertains to the United States (where the organisation is based). Chiropractors in the UK are legally obliged to tell their patients about the risks of any proposed interventions, and, as already pointed out, the UK has a ‘Chiropractic Incident Reporting and Learning System’ (CPiRLS) http://www.cpirls.org/

    But that said, and bearing in mind my concerns in a previous comment about the trustworthiness of chiropractors, it’s interesting to note some comments which are made on pages 42-43 (pp. 40-41 of the original document) of the draft of a revalidation report recently commissioned by the General Chiropractic Council:

    We hope that the introduction of the Chiropractic Patient Incident Reporting and Learning System (CP1RLS) web portal will provide information on the types of patient safety incidents and adverse events that occur in chiropractic from a significantly larger sample of field practitioners than has been considered in previous studies. CPiRLS is anonymised and hence concerns about reputation and potential consequences of reporting should be reduced.

    Nonetheless, the system will still suffer from problems of reporting bias and sample selection: only some chiropractors will report incidents and this may not be a representative sample of all chiropractors whilst those that do report incidents may restrict this to only certain categories of incident (e.g. they may report near misses but not serious adverse events).

    http://www.gcc-uk.org/files/page_file/C-170210-04a.pdf

    How reassuring is that for patients?

  54. Blue Wode wrote

    Here is the death certificate of 39-year-old John Hoffman whose stroke occurred about 3 hours after having a neck adjustment at his chiropractor’s office. He died 6 days later

    First of all I wish to say that I think it’s poor taste to be posting a link to someone’s death certificate on a blog and I would rather not be arguing about the poor man’s death in a forum like this.

    However, having reached this position there are some points that should be made because there’s a lot of information we don’t have regarding the sad demise of Mr Hoffman.

    We don’t know his previous medical history, other than the fact that he had hypertension (the single biggest predisposing factor to stroke) and that the Medical Examiner considered this significant.
    We don’t know what the presenting complaint was.
    We don’t know what pre-treatment tests were performed.
    We don’t know what treatment was administered.
    We don’t know what else Mr Hoffman did on the day he had his stroke.

    What we do know is that there have been many occasions when chiropractors have incorrectly been accused of causing strokes when in fact the stroke had already been in progress at the time the chiropractor saw the patient. I have had a case myself where a patient presented to me with the signs of a stroke in progress. I did not treat her, but referred her directly into emergency medical care. Sadly, the doctors who examined her missed the diagnosis, despite being prompted, and she tragically died a few days later.

    It’s easy to imagine that the Coroner might well have come to the wrong conclusion about the cause of death if I had treated her.

  55. Vossen said: “So now one coroner’s opinion is “evidence” is it?”

    Well. That’s very telling, isn’t it?

    However, David originally said: “Ernst knows perfectly well that there is no evidence that chiropractic treatment has ever caused a death”

    That is a categoric statement and it just takes one counter example to refute it.

    Blue Wode helpfully provided one counter example: a death certificate that certainly appears to be genuine (and you’ve not tried to claim it isn’t) and states that the cause of death was due to, or as a consequence of, a chiropractic cervical manipulation. He has therefore completely demolished your assertion and left it in tatters.

    Trying to save face – but failing miserably – you then try to dig yourself out of your self-dug hole. You regale us with a list of things you don’t happen to know about this case.

    But what you seem to want us to believe is that you, a chiro who knows nothing about this particular sad case knows more than the examining Coroner who performed the autopsy, or that the Coroner didn’t do his job properly.

    I’ve seen many comments here and elsewhere about chiros telling skeptics they can’t possibly have a valid opinion of chiro because they are not chiros and have not had the privilege of the extensive and comprehensive training they’ve had. Have you ever claimed that, David? Are you a Coroner? Yet here we have a chiro asserting that the Coroner might have been wrong in a case you know nothing about. Now, you may know a bit about the musculo-skeletal system, but have you any idea how pathetic you look coming up with these excuses?

    And, as a respectable chiro (you are, aren’t you?) you no doubt abide by your professional duty to respect other healthcare professionals? Don’t you trust other ‘doctors’? Or do you just always know better than them?

    You even try to divert the dear reader with a story about a customer that you (thankfully) noticed was having a stroke. Good for you. But irrelevant and a mere diversionary anecdote. Typical.

    Now, as I see it, your options to reclaim your assertion are:

    1) Provide robust evidence that this particular death certificate is false.
    2) Provide robust evidence that the Coroner was wrong in this specific case.
    3) Admit that your original assertion has been proven demonstrably false and shift your position to say that, well, not many people have been killed by chiro manipulations.

    Which is it to be?

    Oh! I nearly forgot. You said: “It’s easy to imagine that the Coroner might well have come to the wrong conclusion about the cause of death if I had treated her.”

    But a chiro would never come to the wrong conclusion about anything, now would they?

  56. @GG

    So I take it you are either in the same part of the world as me or are an insomniac. If you are an insomniac, perhaps you should consult a chiropractor 😉

    Anyway, I checked out the link – thanks for that.

    First, in his rejoinder, Hayden Thomas appears to use the title of doctor with no reference to the fact he is actually a chiropractor in a letter talking about the effectivenes of chiropractic. Naughty. Especially as I suspect he’s a NZ graduate rather than in possesion of the qualification DC.

    Second, he writes ‘to the suggestion that chiropractic doesn’t work, we would refer Dr Brockie to any number of studies that attest to the safety, efficacy and cost effectiveness of chiropractic care.’ Well the UK GCC tried to do this and look at the mess they made. Perhaps Hayden has access to different studies? I flipping doubt it!

  57. @kjm:

    Vossen said: “So now one coroner’s opinion is “evidence” is it?”

    Well. That’s very telling, isn’t it?

    I am sorry that the irony of my statement did not come across, and although you are correct in the basics of your assertion I will explain why in the context of how it was intended you are not. This is often the problem when discussions like these are joined, so my apologies for lack of rhetorical hygiene.
    A coroner’s opinion is a respectable opinion and one to be borne in mind when judging a situation, but evidence of having established a causal link there is not. Lots of respectable people have opined throughout history but respectability does not maketh evidence. That and that alone was the point I was making. It does not do that for me, it does not do that for said coroner. Secondly, let’s look at the issue of risk. In this particular case, and the few available similar ones it is important to beware of the high potential for post hoc fallacy. The likelihood of post hoc is inversely proportional to the strength of plausibility of causal mechanism. In the face of the difficulty associated with identifying the plausibility of the mechanism one has to have relatively in-depth knowledge of vascular anatomy and pathophysiology. People far cleverer than me said that there isn’t a likely mono-causal mechanism. That then leaves us with one important issue: that of comorbidity. This is the issue David is raising, and rather than excusing the profession of any responsibility, he is rather highlighting the likelihood of this being the reason for the appearance of correlation between manipulation of the upper cervical complex and the occurrence of stroke. This, rather than being a “cheap excuse”, highlights the great responsibility we have to pick up on these issues and refer with urgency. Unfortunately in the one case he mentions, this did not come to a good end. I have been more fortunate myself.
    All in all the evidence points that we are most likely, in our humanity as clinicians, to make mistakes in our evaluation of the comorbidity factors and secondly and separately for our actions to be associated to stroke by complete coincidence.
    This could of course all be wrong, but one could point that the available data on frequency of occurrence of stroke after or close after manipulation of the neck is so low that it is unlikely that the relation is any more than coincidental and occasionally due to comorbidity.
    Of course until there is firm conclusion in this regard, all people using manipulative techniques will have to be mindful of this and respect the lack of solid, factual knowledge. This should then be expressed in their approach to the pat