Where the evidence leads
Google Alerts is a very useful tool for skeptics. It sends you an email whenever the word or phrase you’ve asked for crops up in their searches of news, blogs or other websites. They are excellent for keeping tabs on what’s going on by helping you track new stories and hits.
Naturally, I have one set up for the General Chiropractic Council (GCC), just to see where they crop up on web sites and in the news.
A few days ago, I received a Google Alert about a page that had been recently updated, although the mention of the GCC was from some time ago. It linked to a decision by the Press Complaints Commission (PCC) about complaints made by the GCC against the Daily Telegraph, the Daily Mail and the Guardian about articles published on 9 November 2007.
According to the GCC, the articles said:
- Chiropractors ‘are waste [sic] of money’, Daily Telegraph, Rebecca Smith
- Chiropractors ‘are a waste of time’, Daily Mail, Jenny Hope
- ‘Chiropractors may be no use in treating back pain, study says’, The Guardian, Alok Jha
Nothing new there, then.
The GCC is appalled by a number of reports in today’s press that ‘chiropractic is a waste of time and money’. This wildly inaccurate assertion is based on a small research study looking at acute low back pain only and involving GPs and physiotherapists. The purpose of the study was not to measure the effectiveness of chiropractors.
The press reports defy logic because neither the research study, nor the Lancet’s press release, mentioned chiropractic or concluded that ‘chiropractic was a waste of time and money’. It is sad to see a piece of research misrepresented in this way.
He goes on to say, with no hint of irony:
Chiropractors provide an evidence-based approach based on European-wide guidelines compiled by multidisciplinary teams of experts who reviewed all relevant research.
The main treatments of chiropractic have consistently been shown in reviews to be more effective than the treatments to which they have been compared. Chiropractic intervention is safe, effective and cost-effective in reducing referral to secondary care.
And the GCC’s Annual Report 2007, page 22, says about the case:
The accurate reporting of research outcomes by the media is essential to the public interest.
The GCC complained that the articles were:
…inaccurate, misleading and distorted reporting of the purpose and outcome of a research study
They went on to say:
The GCC is concerned that such reporting is irresponsible and does not serve the public interest. It misleads readers, may prevent members of the public from seeking the help of appropriately qualified, experienced and regulated health professionals, and ultimately undermines the public’s trust in the accuracy and utility of scientific research.
It is likely that such reporting has also undermined the reputation of the chiropractic profession and may have a direct impact on chiropractors’ practices; all chiropractors, apart from a handful, are in private practice. It may also prejudice any chance of increasing public access to chiropractic on the basis of need through NHS funding.
Ah. Reputation. Money. NHS funding.
But they weren’t the only ones concerned by the articles.
Dr Damien O’Dwyer (a chiropractor who doesn’t appear to be a registered with the GMC as a medical practitioner) complained about the Daily Mail and the Guardian and the British Chiropractic Association also complained, apparently. I say apparently because the GCC Newsletter of March 2008 (cached), which tells their side of the story, states that the BCA had also complained to the PCC, but I can find no mention of their complaint on the PCC website or on the BCA’s own website.
The Hancock study
But what got the GCC, the BCA and a chiropractor so incensed with these three articles that they felt the need to complain to the PCC and demand the record be set straight?
Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial, M.J. Hancock et al, (Lancet 2007; 370:1638-43)
According to the GCC’s complaint:
The research study did not conclude that chiropractors are a waste of time and money, or of no use in treating back pain, as reported. Chiropractors were not mentioned in the research study at all. The purpose of the study was not to measure the effectiveness, or otherwise, of chiropractors or a single manipulative technique used by chiropractors, physiotherapists, osteopaths and others. [Their emphasis]
The GCC told their members (19):
The articles gave an inaccurate, misleading and distorted view of research published in the Lancet…
No direct comparison can be made from the results of the aforementioned study and the treatment offered by BCA chiropractors for a number of reasons:
- The study did not address chiropractic only spinal mobilisation carried out by physiotherapists. The majority of participants had low-velocity mobilisation techniques and only 5% experienced high velocity techniques. Chiropractic manipulation is based predominantly on high velocity techniques, so the results are therefore not comparable with chiropractic treatment
- There is no indication to suggest that the physiotherapists are specialist manipulative practitioners as BCA chiropractors are – the results could well have been different had chiropractors been involved with this study rather than physiotherapists
- The level of training and education is not comparable. The British Chiropractic Association only accepts graduates who have undergone a minimum of a four year full-time internationally-accredited degree course at an internationally-recognised college of chiropractic education
At least the GCC and the BCA were in agreement about the fact that the study by Hancock et al. clearly had nothing whatsoever to do with chiropractic, chiropractic subluxations or chiropractic manipulations so it was therefore wrong to conclude from it that chiropractic was a waste of time or money.
To make amends for this heinous misrepresentation of the truth, the GCC demanded:
In the GCC’s view, the best outcome to our complaint would be
- Corrections and clarifications printed in a prominent position in each paper
- The PCC publishing a specific good practice guideline for journalists on reporting research outcomes, or endorsing and circulating the SIRC guidelines mentioned above
- The PCC upholding the GCC’s complaint and its judgement published in a prominent position in each paper
The end result of the complaints was that all three papers published corrections, acknowledging that the study was not about chiropractic and that there were wrong to say the horrible things they did about chiropractors.
I’m glad that’s clear.
Remember the GCC’s Bronfort Report?
As a result of my complaints — and presumably because they didn’t already know what the evidence base was — Bronfort and four other chiropractors were commissioned by the GCC to look at the totality of evidence for chiropractic and they gathered an impressive 322 references. One of these was a certain study by Hancock et al., cited as reference 37 in the Bronfort Report — the very same study that the GCC complained about.
What did Bronfort have to say about it?
Hancock et al  found spinal mobilization in addition to medical care was no more effective than medical care alone at reducing the number of days until full recovery for acute LBP. This study had a low risk of bias.
And, in summary:
Moderate evidence that adding spinal mobilization to medical care does not improve outcomes for acute LBP in adults .
Assessing all the studies that Bronfort found, they concluded there was moderate positive evidence for acute lower back pain (LBP) from spinal manipulation/mobilisation.
But why was the Hancock et al. study (which has nothing to do with chiropractic, remember) ever considered by Bronfort? The GCC has made it abundantly clear that Hancock et al. has nothing whatsoever to do with chiropractic. Even if Bronfort was not aware of this at the time, you’d have thought someone at the GCC would have read it and noticed this irrelevant Hancock study and either asked Bronfort to remove it or issue an amendment to it.
Neither has happened.
So, with the GCC having rejected the Hancock et al. study as having nothing to do with chiropractic, where does that leave Bronfort? What happens if you take the Hancock study out of the Bronfort report? Well, removing Hancock et al. makes the remaining evidence look more positive in favour of chiropractic being effective for acute LBP.
I’ll go where the evidence leads and if that leads to show that chiropractic is effective for some conditions, then so be it. That’s what the evidence says. (But there is still the massive problem of the complete lack of a plausible mechanism of action, of course — something essential for Science-Based Medicine).
However, if the Hancock study is to be removed from Bronfort because it had nothing to do with chiropractic manipulation, then we must also remove all the other papers that Bronfort cited that were not explicitly to do with chiropractic and chiropractic manipulation. That’s the only sensible things to do — you can’t cherry pick, after all, can you? Reject one study because it has nothing to do with chiropractic and you must reject all others.
That includes the ones that were for osteopathic manipulation as well as those just described as ‘manipulation’ After all, as any chiro will tell you, a chiropractic adjustment is not an osteopathic adjustment and is not just any old spinal adjustment.
Before looking further at Bronfort, it’s worth considering some definitions and how chiropractors try to define what they do: to be taken seriously, chiropractors would need to properly and fully define what they mean by chiropractic manipulation. If they don’t, they are no different to witches casting spells.
Chiropractors want to be unique. They want to be seen to be unique. They need to be unique. Many want chiropractic to be seen as something completely different to other ‘healthcare professions’. Their USP is chiropractic manipulations: high velocity low amplitude manipulations if you will. According to the BCA, even Physiotherapists only perform using low velocity techniques: it’s the speed of the manipulation that is critical, apparently.
Take away the chiropractic manipulation then they are no longer those unique manual practitioners they so desperately crave to be. Of course, part of the marketing is to give their spinal manipulations a special, unique name: chiropractic adjustments. It is the ‘specific yet gentle chiropractic adjustments’ that create the differential with other professions.
But defining what chiropractic is seems somewhat elusive — even to chiropractors. There have been many attempts by chiropractors to explain their ‘art’ to non-chiropractors, but these always turn out to be circular (and therefore explaining nothing) or end up relying on some variation of a hypothesis of the vertebral subluxation complex (VSC). Attempts to explain the VSC as anything tangible are, of course, thwarted by the complete lack of evidential proof of its existence. Attempts to explain further flounder in a sea of self-referential gobbledegook.
The GCC have been very cagey about exactly what chiropractic is and isn’t. They changed their guidance on the VSC a few months ago and modified it after pressure from chiropractors. The pressure group (the AUKC) had another meeting with the GCC earlier this week and it remains to be seen what further concessions they have managed to squeeze out of the GCC after their Council meeting yesterday.
It was also agreed at this meeting [with the GCC on 17 August 2010] that the term Subluxation would again be included in the “Frequently Asked Questions” (FAQs) – A definition will be discussed and agreed at the next Communications Advisory Group meeting on 10th December 2010
Why does it take so long for chiropractors to agree on a definition? Perhaps they are just having trouble dumbing it down enough for us non-chiropractors?
But this is not just a UK problem. A recent study by Jann Bellamy (Legislative alchemy: the US state chiropractic practice acts) found 50 different definitions of chiropractic in the 50 US States: in 21 States, there was direct reference to a subluxation or similar; 23 States talked about ‘malpositioned vertebrae’ that interfere with nerve ‘flow’, with the final six simply referring to what is taught at a chiropractic training establishment (but who all teach as if the VSC was real).
Bellamy has this to say about spinal manipulation:
As with the word ‘subluxation’, the term ‘spinal manipulation’ is a source of confusion. Spinal manipulation is a form of manual therapy practised by chiropractors, physical therapists, osteopaths and medical doctors specialising in physiatry. Many different techniques are used in spinal manipulation, but in general it includes the application of varying amounts of force to the spine so that the selected joint is moved beyond its restricted range of movement.21 To physical therapists and medical doctors, the exclusive purpose of spinal manipulation is to reduce pain, increase joint range of motion, and address other physical manifestations of joint impairment.21,22 Osteopaths use the term more broadly, but also employ spinal manipulation for these purposes, as do chiropractors.21 However, there is one important distinction: chiropractors also believe spinal manipulation can be used to reduce the chiropractic subluxation thereby restoring ‘neural integrity.’23 Most chiropractors prefer the term ‘adjustment’ to ‘manipulation’ to distinguish this distinctive feature from other forms of spinal manipulation, but both appear in the literature and are used interchangeably.
To my mind, this simply smacks of chiropractors struggling to find and hang on to their USP — the one that allows them to appear to be a unique ‘primary healthcare profession‘. They may do other things as well (and some are no doubt of benefit to their customers — massage and being a listening ear to their woes, for example), but their USP is the chiropractic manipulation, made so by chiropractors themselves.
Back to Bronfort.
For non-specific LBP, Bronfort looked at five systematic reviews, covering some 70 RCTs. Bronfort found that:
…spinal manipulation was superior to sham intervention and similar in effect to other commonly used efficacious therapies such as usual care, exercise, or back school.
Which is what we knew already: it’s no better than other interventions.
In the evidence summary, Bronfort lists the evidence for acute LBP:
- Moderate quality evidence that spinal manipulation/mobilization is an effective treatment option for acute LBP in adults [18,24].
- Moderate evidence that adding spinal mobilization to medical care does not improve outcomes for acute LBP in adults .
The last one is the Hancock study, leaving just references 18 and 24:
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. (Full text)
Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. (Full text)
The first does talk about chiropractic and it covered 69 studies in 12 systematic reviews, but few of the studies were specifically concerned chiropractic manipulation and it also included the discredited UK BEAM trial.
The second was written with the help of Alan Breen, currently a member of the GCC Council and Professor of Musculoskeletal Health at the Anglo-European College of Chiropractic, and another chiropractor from Denmark.
Before looking at that study further, it’s worth repeating what Breen said about evidence in 2009:
To portray only part of the relevant information in a critique is itself pseudoscience, yet strong ontological commitment to only part of the knowledge base seems often to be the stance taken to contest the scientific basis of Chiropractic. Rather like psychiatry, debates about musculoskeletal practice need to go beyond positivist science and recognize that we have entered a more democratic and inclusive, post-normal age.
For a thorough analysis of this, see AP Gaylard’s blog post: In praise of chiropractic?
The European guidelines:
…also aim to inform the general public, patients with low back pain, health care providers (for example, general practitioners, physiotherapists, chiropractors, manual therapists, occupational physicians, orthopaedic surgeons, rheumatologists, rehabilitation physicians, neurologists, anaesthesiologists and other health care providers dealing with patients suffering from acute nonspecific low back pain)…
It tells us who might treat acute LBP:
Treatment for acute low back pain
Various health care providers may be involved in the treatment of acute low back pain in primary care. Although there may be some variations between European countries, general practitioners, physiotherapists, manual therapists, chiropractors, exercise therapists…
However, that’s the last ever mention of chiropractic.
The guidelines gives recommendations for: Information and reassurance; Bed rest; Advice to stay active; Exercise therapy; Analgesia (paracetamol, nsaids, muscle relaxants); Epidural steroids, before finally getting round to ‘Spinal manipulation’.
The authors found six systematic reviews and one Cochrane review. They concluded that spinal manipulation, compared to placebo/sham, provided only short-term benefits, with no long-term benefits. Compared to other treatments:
Spinal manipulative treatment had no statistically or clinically significant advantage on pain and functional status over general practitioner care, analgesics, physical therapy, exercises, or back school.
But again, this is spinal manipulation, not chiropractic manipulation.
Chiropractors can’t have it both ways: chiropractors can’t claim to be unique amongst the manual therapists because of their techniques, yet claim any evidence for their particular ‘art’ from the studies that were not about chiropractic manipulations. The GCC has made this perfectly clear.
So, the GCC can’t maintain that Hancock is irrelevant because it’s not about chiropractic manipulations, yet allow their prized Bronfort Report off the hook when it cites trials mainly not about chiropractic.
Once all those non-chiropractic manipulations have been removed from the Bronfort Report, what’s left?
Not a jot.