MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

The UK General Chiropractic Council has commissioned a survey of chiropractic patients’ views of chiropractic. Initially, 600 chiropractors were approached to recruit patients, but only 47 volunteered to participate. Eventually, 70 chiropractors consented and recruited a total of 544 patients who completed the questionnaire in 2012. The final report of this exercise has just become available.

I have to admit, I found it intensely boring. This is mainly because the questions asked avoided contentious issues. One has to dig deep to find nuggets of interest. Here are some of the findings that I thought were perhaps mildly intriguing:

15% of all patients did not receive information about possible adverse effects (AEs) of their treatment.

20% received no explanations why investigations such as X-rays were necessary and what risks they carried.

17% were not told how much their treatment would cost during the initial consultation.

38% were not informed about complaint procedures.

9% were not told about further treatment options for their condition.

18% said they were not referred to another health care professional when the condition failed to improve.

20% noted that the chiropractor did not liaise with the patient’s GP.

I think, one has to take such surveys with more than just a pinch of salt. At best, they give a vague impression of what patients believe. At worst, they are not worth the paper they are printed on.

Perhaps the most remarkable finding from the report is the unwillingness of chiropractors to co-operate with the GCC which, after all, is their regulating body. To recruit only ~10% of all UK chiropractors is more than disappointing. This low response rate will inevitably impact on the validity of the results and the conclusions.

It can be assumed that those practitioners who did volunteer are a self-selected sample and thus not representative of the UK chiropractic profession; they might be especially good, correct or obedient. This, in turn, also applies to the sample of patients recruited for this research. If that is so, the picture that emerged from the survey is likely to be be far too positive.

In any case, with a response rate of only ~10%, any survey is next to useless. I would therefore put it in the category of ‘not worth the paper it is printed on’.

 

11 Responses to More dismal chiropractic research

  • Prof. Ernst wrote: “It can be assumed that those practitioners who did volunteer are a self-selected sample and thus not representative of the UK chiropractic profession; they might be especially good, correct or obedient.”

    I have had a slow read through the entire document and have arrived at the same conclusion. For example on p.8 it says “of those surveyed, around 20% of respondents reported that they had had an unexpected or unpleasant reaction to their treatment”. The fact that it was only 20% is interesting. It reminds me of this valid comment by Prof. Ernst on an AECC survey on the safety of chiropractic manipulation of the cervical spine:

    Quote:
    “In my view, the most confusing aspect about the results of this survey is the fact that the incidence of minor adverse events is so low. Previous studies have repeatedly shown it to be around 50%. The discrepancy requires an explanation. There could be several but mine goes as follows: the participating chiropractors were highly self-selected. Thus they were sufficiently experienced to select low-risk patients (in violation of the protocol). This explains the low rate of minor adverse events and begs the question whether the incidence of serious adverse events is reliable. Studies of this nature are very difficult to conduct such that we can trust the results. One of the problems is that one has to rely on the honesty of the participating therapists who could have a very strong interest in generating a reassuring yet unreliable picture about the safety of their intervention.”
    http://onlinelibrary.wiley.com/doi/10.1211/fact.13.1.0020/full

    (For those interested, my observations on the authors’ response to Edzard Ernst are written up here: http://www.ukskeptics.com/forum/showthread.php/1610-Value-of-chiropractors-questioned?p=32759&viewfull=1#post32759 )

    With regard to his assumption that the chiropractors who volunteered were a self-selected sample, Prof. Ernst went on to say: “This, in turn, also applies to the sample of patients recruited for this research. If that is so, the picture that emerged from the survey is likely to be far too positive.”

    I suspect that’s also an accurate view. For example, tucked away on p.17 of the document is the following:

    Quote
    “However, it is important to sound a note of caution in terms of how representative the patients involved in this study are of all patients who seek chiropractic care. The nature of this study means that most of the patients who contributed are either currently receiving treatment or have had on-going chiropractic care in the recent past. Those patients who ceased chiropractic care after a small number of treatments, perhaps because they were unhappy with their care, may well be under-represented.”

    Some other points from my reading of the document:

    On p.9 it says that some chiropractors felt that the brief for the study placed undue emphasis on risks of chiropractic care, but, IMO, it doesn’t go far enough. Bearing in mind that the survey was part of the GCC’s revalidation process, it’s worth remembering that the GCC recently commissioned a draft document on revalidation, the purpose of which was to provide an analysis of the risks and benefits of chiropractic with the aim of establishing if there was a business case for revalidation (it was subsequently dropped, but then reinstated). In section 5.72 of that document, the British Chiropractic Association admitted that its members had *caused* patient rib fracture injuries, and in sections 5.13 (along with the McTimoney Chiropractic Association), and 5.64, the Scottish Chiropractic Association apparently ignored the request for details of patient incidents and complaints. See here:
    http://www.gcc-uk.org/files/page_file/C-170210-04a.pdf

    There are likely to be many injuries caused by chiropractic treatment which are never reported, not least because chiropractors have no reliable adverse event reporting systems in place, and don’t seem to view establishing any as a priority.

    On p.25 we’re told that “Only a very small number of people interviewed could recall that the GCC registration was clearly indicated by the chiropractor”.

    Perhaps that’s because a huge number of chiropractors recently took part in a vote of no confidence in the GCC:
    http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1827-alliance-of-uk-chiropractors-october-2010-newsletter.html

    In relation to that ‘no confidence’ vote, it’s quite worrying that it says on p.26 that “Some patients interviewed also seemed unclear about the difference between membership of a professional body and registration with the GCC”.

    Finally, on p.39, adverse events experienced by patients include headache, tingling/numbness in legs or arms, dizziness or light headedness, and nausea – all of which could be signs of stroke following chiropractic neck manipulation although the survey doesn’t make that connection.

    Seems to me that the whole exercise was designed for marketing purposes rather than a means of advancing patient protection.

    • surveys of this nature are akin to a researcher going into a vegetarian restaurant and ask people whether they like meat.
      or better still poling the vatican about the value of catholicism. everyone knows they are useless but, in alt med, they are popular like anything.

      • Like in most non-RCT studies then… (and even those to some degree or other in fact)

      • Or interviewing everyone who arrives at a supermarket checkout with peanut butter in their basket, and asking them what they think of peanut butter. To the untrained eye, this might give the staggerring impression that peanut butter is much tastier than the controversy suggests…

  • Dear Prof Ernst,

    Just a quick question that is slightly off topic – In your opinion is there a role for any manual therapy in the treatment of musculoskeletal complaints? If so, what type of treatment?

    Many thanks

  • i try not to have opinions but hope to be evidence-based.
    the evidence, in a nutshell, suggests that manipulation mobilization and massage are roughly equally as effective [or ineffective] as any other conservative treatment for back pain.
    the area of MUSCULOSKELETAL COMPLAINTS is vast but for most other conditions, the evidence is shaky or non-existent.

  • It’s worth highlighting that page 7 of the survey document admits to problems with ambiguity. We’re told that:

    Quote

    “Survey respondents did not have particularly high expectations that the chiropractor would refer them to other agencies or contact their GP, should this be needed (86%); a significant percentage said this did not happen (63%), but it is not clear whether this relates to the expectation not being delivered or whether a referral was not required.”

    That could be a way of playing down any reluctance that chiropractors might have regarding contacting their patients’ GPs. Such reluctance is likely stem from chiropractors’ fears that contacting GPs could cause patients to terminate lengthy treatment plans and consequently see chiropractors lose valuable business. Indeed, the GCC’s Patient Information Leaflet seems to be more chiropractor friendly than patient friendly. This from page 4:

    Quote:

    Do I need to tell my GP?
    You do not need to let your GP know unless you want to. With your permission, your chiropractor may send a report to your GP, with details of your condition and the treatment you are receiving. This is because your GP holds all your medical records, and it is in your interests for them to be complete and up to date.
    http://www.gcc-uk.org/files/link_file/WhatCanIExpectMar10_0492_1_WEB.pdf

    IMO, patients would have a far greater understanding of what they would getting themselves into if that were to read:

    Do I need to tell my GP?
    There is no compulsion on chiropractors to inform your GP that you are receiving chiropractic treatment. Your chiropractor may ask for your permission to send a report to your GP, but in most instances he/she will not. Although your GP holds all your medical records, and it is in your interests for these records to be complete and up to date, it is likely that your chiropractic treatment will not be recorded unless you specifically ask your chiropractor to write to your GP.

  • I know what we’ll do. Lets send a survey to all Americans asking them if they prefer man utd or man city. That way we’ll get a good reflection of the performance of each team that season. That’s the good design of a peanut butter survey!

    Why would you ask people who don’t go to a chiropractor about their chiropractic experience?

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