MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Five years ago to the day, Simon Singh and I published an article in The Daily Mail to promote our book TRICK OR TREATMENT… which was then about to be launched. We recently learnt that our short article prompted a “confidential” message by the BRITISH CHIROPRACTIC ASSOCIATION to all its members. “Confidential” needs to be put in inverted commas because it is readily available on the Internet. I find it fascinating and of sufficient public interest to reproduce it here in full. I have not altered a thing in the following text, except putting it in italics and putting the section where the BCA quote our text in bold for clarity.

CONFIDENTIAL FOR BCA MEMBERS ONLY

Information for BCA members regarding an article in the Daily Mail – April 8th 2008

A double page spread appeared in the edition of the Daily Mail April 8th 2008 on page 46 and 47 and titled ‘Alternative Medicine The Verdict’.

The article was written by Simon Singh and Edzard Ernst and is a publicity prelude to a book they have written called ‘Trick or Treatment? Alternative Medicine on Trial’, which will be published later this month.

The article covers Alexander Technique, Aromatherapy, Flower Remedy, Chiropractic, Hypnotherapy, Magnet Therapy and Osteopathy.

The coverage of Chiropractic follows a familiar pattern for E Ernst. The treatment is oversimplified in explanation, with a heavy emphasis on words like thrust, strong and aggressive. There is tacit acknowledgement that chiropractic works for back pain, but then there is a long section about caution regarding neck manipulation. The article concludes by advising people not to have their neck manipulated and not to allow children to be treated.

CHIROPRACTIC THERAPY

WHAT IS IT? Chiropractors use spinal manipulation to realign the spine to restore mobility. Initial examination often includes X-ray images or MRI scans.

Spinal manipulation can be a fairly aggressive technique, which pushes the spinal joint slightly beyond what it is ordinarily capable of achieving, using a technique called high-velocity, low-amplitude thrust – exerting a relatively strong force in order to move the joint at speed, but the extent of the motion needs to be limited to prevent damage to the joint and its surrounding structures.

Although spinal manipulation is often associated with a cracking sound, this is not a result of the bones crunching or a sign that bones are being put back; the noise is caused by the release and popping of gas bubbles, generated when the fluid in the joint space is put under severe stress.

Some chiropractors claim to treat everything from digestive disorders to ear infections, others will treat only back problems.

DOES IT WORK? There is no evidence to suggest that spinal manipulation is effective for anything but back pain and even then conventional approaches (such as regular exercise and ibuprofen) are just as likely to be effective and are cheaper.

Neck manipulation has been linked to neurological complications such as strokes – in 1998, a 20-year-old Canadian woman died after neck manipulation caused a blood clot which led to stroke. We would strongly recommend physiotherapy exercises and osteopathy ahead of chiropractic therapy because they are at least effective and much safer.

If you do decide to visit a chiropractor despite our concerns and warnings, we very strongly recommend you confirm your chiropractor won’t manipulate your neck. The dangers of chiropractic therapy to children are particularly worrying because a chiropractor would be manipulating an immature spine.

Daily Mail 2008 April 8th.

As we are aware that patients or potential patients of our members will be confronted with questions regarding this article, we have put together some comment and Q&As to assist you.

• Please consider this information as strictly confidential and for your use only.

• Only use this if a patient asks about these specific issues; there is nothing to be gained from releasing any information not asked for.

• Do not duplicate these patient notes and hand out direct to the patient or the media; these are designed for you to use when in direct conversation with a patient.

The BCA will be very carefully considering any questions or approaches we may receive from the press and will respond to them using specially briefed spokespeople. We would strongly advise our members not to speak directly to the press on any of the issues raised as a result of this coverage.

Please note that In the event of you receiving queries from the media, please refer these direct to BCA (0118 950 5950 – Anne Barlow or Sue Wakefield) or Publicasity (0207 632 2400 – Julie Doyle or Sara Bailey).

The following points should assist you in answering questions that patients may ask with regard to the safety and effectiveness of chiropractic care. Potential questions are detailed along with the desired ‘BCA response’:

“The Daily Mail article seems to suggest chiropractic treatment is not that effective”

Nothing could be further from the truth. The authors have had to concede that chiropractic treatment works for back pain as there is overwhelming evidence to support this. The authors also contest that pain killers and exercises can do the job just as well. What they fail to mention is that research has shown that this might be the case for some patients, but the amount of time it may take to recover is a lot longer and the chance of re-occurrence of the problem is higher. This means that chiropractic treatment works, gets results more quickly and helps prevent re-occurrence of the problem. Chiropractic is the third largest healthcare profession in the world and in the UK is recognised and regulated by the UK Government.

“The treatment is described as aggressive, can you explain?”

It is important to say that the authors of the article clearly have no direct experience of chiropractic treatment, nor have they bothered to properly research the training and techniques. Chiropractic treatment can take many forms, depending on the nature of the problem, the particular patient’s age and medical history and other factors. The training chiropractors receive is overseen by the government appointed regulator and the content of training is absolutely designed to ensure that an individual chiropractor understands exactly which treatment types are required in each individual patient scenario. Gentle technique, massage and exercise are just some of the techniques available in the chiropractor’s ‘toolkit’. It is a gross generalisation and a demonstration of lack of knowledge of chiropractic to characterise it the way it appeared in the article.

“The article talked about ‘claims’ of success with other problems”

There is a large and undeniable body of evidence regarding the effectiveness of chiropractic treatment for musculoskeletal problems such as back pain. There is also growing evidence that chiropractic treatment can help many patients with other problems; persistent headaches for example. There is also anecdotal evidence and positive patient experience to show that other kinds of problems have been helped by chiropractic treatment. For many of these kinds of problems, the formal research is just beginning and a chiropractor would never propose their treatment as a substitute for other, ongoing treatments.

“Am I at risk of having a stroke if I have a chiropractic treatment?”

What is important to understand is that any association between neck manipulation and stroke is extremely rare. Chiropractic is a very safe form of treatment.

Another important point to understand is that the treatments employed by chiropractors are statistically safer than many other conservative treatment options (such as ibuprofen and other pain killers with side effects such as gastric bleeding) for mechanical low back or neck pain conditions.

A research study in the UK, published just last year studied the neck manipulations received by nearly 20,000 chiropractic patients. NO SERIOUS ADVERSE SIDE EFFECTS WERE IDENTIFIED AT ALL. In another piece of research, published in February this year, stroke was found to be a very rare event and the risk associated with a visit to a chiropractor appeared to be no different from the risk of a stroke following a visit to a GP.

Other recent research shows that such an association with stroke may occur once in every 5.85 million adjustments.

To put this in context, a ‘significant risk’ for any therapeutic intervention (such as pain medication) is defined as 1 in 10,000.

Additional info: Stroke is a natural occurring phenomenon, and evidence dictates that a number of key risk factors increase the likelihood of an individual suffering a stroke. Smoking, high blood pressure, high cholesterol and family medical histories can all contribute; rarely does a stroke occur in isolation from these factors. Also, stroke symptoms can be similar to that of upper neck pains, stiffness or headaches, conditions for which patients may seek chiropractic treatment. BCA chiropractors are trained to recognise and diagnose these symptoms and advise appropriate mainstream medical care.

“Can you tell if I am at risk from stroke?”

As a BCA chiropractor I am trained to identify risk factors and would not proceed with treatment if there was any doubt as to the patient’s suitability. Potential risks may come to light during the taking of a case history, which may include: smoking, high cholesterol, contraceptive pill, Blood clotting problems/blood thinning meds, heart problems, trauma to the head etc and on physical examination e.g. high blood pressure, severe osteoarthritis of the neck, history of rheumatoid arthritis

“Do you ever tell patients if they are at risk?”

Yes, I would always discuss risks with patients and treatment will not proceed without informed consent.

“Is it safe for my child to be treated by a chiropractor”

It is a shame that the article so generalises the treatment provided by a chiropractor, that it makes such outrageous claims. My training in anatomy, physiology and diagnosis means that I absolutely understand the demands and needs of spines from the newborn baby to the very elderly patient. The techniques and treatments I might use on a 25 year old are not the same as those I would employ on a 5 year old. I see a lot of children as patients at this clinic and am able to offer help with a variety of problems with the back, joints and muscles. I examine every patient very thoroughly, understand their medical history and discuss my findings with them and their parents before undertaking any treatment.

- Chiropractic is a mature profession and numerous studies clearly demonstrate that chiropractic treatment, including manipulative and spinal adjustment, is both safe and effective.

- Thousands of patients are treated by me and my fellow chiropractors every day in the UK. Chiropractic is a healthcare profession that is growing purely because our patients see the results and GPs refer patients to us because they know we get results!

This article is to promote a book and a controversial one at that. Certainly, in the case of the comments about chiropractic, there is much evidence and research that has formed part of guidelines developed by the Royal Society of General Practitioners, NICE and other NHS/Government agencies, has been conveniently ignored. The statements about chiropractic treatment and technique demonstrate that there has clearly been no research into the actual education that chiropractors in the UK receive – in my case a four year full-time degree course that meets stringent educational standards set down by the government appointed regulator.

Shortly after the article in The Daily Mail, our book was published and turned out to be much appreciated by critical thinkers across the globe — not, however, by chiropractors.

At the time, I did, of course, not know about the above “strictly confidential” message to BCA members, yet I strongly suspected that chiropractors would do everything in their power to dispute our central argument, namely that most of the therapeutic claims by chiropractors were not supported by sufficient evidence. I also knew that our evidence for it was rock solid; after all, I had researched the evidence for or against chiropractic in full depth and minute detail and published dozens of articles on the subject in the medical literature.

When, one and a half weeks after our piece in the Mail, Simon published his now famous Guardian comment stating that the BCA “happily promote bogus treatments”, he was sued for libel by the BCA. I think the above “strictly confidential” message already reveals the BCA’s determination and their conviction to be on firm ground. As it turned out, they were wrong. Not only did they lose their libel suit, but they also dragged chiropractic into a deep crisis.

The “strictly confidential” message is intriguing in several more ways – I will leave it to my readers to pick out some of the many gems hidden in this text. Personally, I find the most remarkable aspect that the BCA seems to attempt to silence its own members regarding the controversy about the value of their treatments. Instead they proscribe answers (should I say doctrines?) of highly debatable accuracy for them, almost as though chiropractors were unable to speak for themselves. To me, this smells of cult-like behaviour, and is by no means indicative of a mature profession – despite their affirmations to the contrary.

63 Responses to “Strictly confidential”- for chiropractors only

  • Edzard Ernst wrote: “I will leave it to my readers to pick out some of the many gems hidden in this text.”

    Three leap out immediately.

    Re the BCA’s claim “research study in the UK, published just last year [2007] studied the neck manipulations received by nearly 20,000 chiropractic patients. NO SERIOUS ADVERSE SIDE EFFECTS WERE IDENTIFIED AT ALL”

    I’m sure that readers will be interested to know that the above study caused Professor Ernst to question the integrity of the UK chiropractic profession [Focus on Alternative and Complementary Therapies, Vol.13. Issue 1. March 2008, pp43-44). The study in question was Thiel HW, Bolton JE, Docherty S, Portlock JC. Safety of chiropractic manipulation of the cervical spine: a prospective national survey. Spine 2007; 32: 2375–8. Here is the most pertinent part of Prof. Ernst’s critique of it:

    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.”

    The survey’s lead authors, J E Bolton and H W Thiel, (of the Anglo European College of Chiropractic) responded with this:

    Quote
    “In endeavouring to provide research evidence and in debating its limitations, we should not lose sight of the bigger picture. In the UK alone, there is an estimated 4 million manipulations of the neck carried out by chiropractors each year. In the absence of any significant numbers of reported serious events (i.e. stroke or death), including those in which a causal link is based on extremely weak evidence, there can be little doubt that the risk is very low.”

    Note that Bolton and Thiel say “In the UK alone, there is an estimated 4 million manipulations of the neck carried out by chiropractors each year”, yet in October 2007, in a letter to the Journal of the Royal Society of Medicine (in response to Ernst’s July 2007 Adverse effects of spinal manipulation systematic review), they said “In the UK, there are estimated to be well over two million cervical spine manipulations by chiropractors each year.” http://www.jrsm.org/cgi/content/full/100/7/330

    How can that estimate have doubled in less than 6 months?

    Further, they say that “In the absence of any significant numbers of reported serious events (i.e. stroke or death), including those in which a causal link is based on extremely weak evidence, there can be little doubt that the risk is very low.” But what they don’t say is that there has never been a reliable reporting system for chiropractic patients in the UK (or elsewhere for that matter) who have experienced serious adverse effects associated with spinal manipulation.

    Bias anyone? Trustworthy?

    Re the BCA’s claim that “in another piece of research, published in February this year [2008], stroke was found to be a very rare event and the risk associated with a visit to a chiropractor appeared to be no different from the risk of a stroke following a visit to a GP.”

    Unfortunately, that paper doesn’t say what chiropractors think it says. Just like the BCA’s “plethora” of evidence which was completely demolished by the scientific community within 48 hours of its publication, the above research from February 2008 was shown, very swiftly, to be fatally flawed. See here: http://tinyurl.com/bp7dkn3

    With reference to the BCA’s instruction to their members to say “Yes, I would always discuss risks with patients and treatment will not proceed without informed consent.”

    How disingenuous of them. Even if BCA chiropractors did always discuss risks with patients, it has long been demonstrated that, overall in the UK chiropractic profession, huge numbers of chiropractors contravene their code of ethics in that regard:

    Quote
    “The Bournemouth team sent questionnaires about risk-related issues to 200 randomly selected UK chiropractors and received 92 responses. Their results show, among other things, that “only 45% indicated they always discuss [the risks of cervical manipulation] with patients …In plain language, this means that the majority of UK chiropractors seem to violate the most basic ethical standards in healthcare. If we assume that the 92 responders were from the more ethical end of the chiropractic spectrum, it might even be the vast majority of UK chiropractors who are violating the axiom of informed consent.”
    http://tinyurl.com/cxta3a6

    Quote
    “Results suggest that valid consent procedures are either poorly understood or selectively implemented by UK chiropractors.”
    http://www.ncbi.nlm.nih.gov/pubmed/15726031?dopt=Abstract

    Quote
    “… a patient’s autonomy and right to self-determination may be compromised when seeking chiropractic care. Difficulties and omissions in the implementation of valid consent processes appear common, particularly in relation to risk. Practitioners felt that a serious adverse event occurred so infrequently that this, coupled with a lack of convincing evidence regarding the risk associated with certain treatment, rendered the routine discussion of major risk unnecessary.”
    [Ref: Langworthy JM, Cambron J. Consent: its practices and implications in United kingdom and United States chiropractic practice. J Manipulative Physiol Ther. 2007 Jul-Aug;30(6):419-31]
    http://tinyurl.com/6ajn5d

    IMO, it’s very apt that chiropractors are also known as “manipulators”.

  • very good points!
    i think they are rather crafty manipulators; what i did not appreciate until i saw their “secret message” is that they also manipulate themselves.

  • Are there any long term term studies of chiro in relation to lower back pain? My experience is that it provides symptomatic relief only, and that repeat visits are requires to keep the symptoms at bay, whereas physiotherapy has the tools to address the underlying problems of posture, lack of muscle tone etc.

    • This is of course an important point. The goal of a physiotherapist is to discharge a cured patient. The goal of a chiropractor is to keep them coming back. Even if they had the ability to cure low back pain rather than provide temporary symptomatic relief, they seem, from all the available evidence, to have no interest in doing so.

      The lesson I draw from the debate around chiro is that it may be as effective as conventional manipulative therapies for some forms of pain, but there’s no real evidence that it is any more effective. Chiropractors are, as a group, inclined to promote antivaccinaton nonsense, conduct potentially dangerous cervical manipulations for which there is no real supporting evidence of benefit to offset the risks, and many still believe in the nonsensical “chiropractic subluxation”. The trade concentrates very strongly on “practice building” with endless seminars, books and workshops telling you how to get healthy people to sign up and keep them coming.

      I can see absolutely no justification for chiropractic being allowed to continue. It is a systematic deception. Any chiropractor who is genuinely motivated to help patients can easily retrain as a physiotherapist, and the balance should just go and get a proper job.

      • the respectable end of the chiro-spectrum is almost indistinguishable from physio – except physios do much more than treating bad backs. so, there is little justification for those chiros to practice. the non-respectable end is certainly not worth having. so….? i think Guy has a good point.

  • Yikes, you need to stop these poisonous thoughts.

    Please contact a chiropractic school research department for clarification on research, philosophy, what’s taught in school and how practice is run. Or contact the American Chiropractic Association or International Chiropractic Association. What you’re doing may be view as borderline illegal. I envy you for trying to empower individuals with knowledge. In fact, I wish there was more like you but what you’ve stated above is incorrect in many areas. In Chiro schoo, I’ve learned from our guidelines (Section 331.030 Aricle 14f) states “Attempting to attact patronage in any manner which castigates, impugns, disparages, discredits or attacks other healing arts and sciences …” is subject to denail, revocation, or suspension of license. I wouldn’t be suprised if your MD guidelines said the exact same thing since in 1985/86 the AMA lost to the ACA for antitrust laws (boycotting Chirorpactic care).

    Chiropractic care can offer many benefits to patients. I see it everyday now. I chuckled some when you stated above that a patient should see a Osteopath or Phystiotherapist instead of a DC cause it’s ” at least effective and safer”. Osteopaths and Phystiotheraptis adjust the spine too! That’s why there’s a DPT program now (Doctor of Physicsal Therapy). They’re kinda like us but they don’t have a 4 year program like us. Their’s is 3 years. And they don’t spend nearly the same amount of time learning the adjusting art like a DC. Hahah!

    Again, please contact someone. You could start with the head of Cleveland Chiropractic Research Department. Here’s the their site with names. http://www.cleveland.edu/knowledge-resources/research/research-team/

    • are you for real?
      borderline illegal?
      are you sure you don’t mean the BCA?

      • I tried reaching out & I see what road you want to take so I’m limiting time spent here.

        Developing research in Chiropractic is very hard to do since the technique can’t readily produce a sham model like in Medicine. I believe research in human surgery experiences this same dilemna. In addition, funding for chiropractic research didn’t pick up witll after Wilk v AMA in 1986. Before this AMA prevented grants and funding to chiropractic research. So yes, there are areas that need more research but there’s a lot of great stuff out there including multiple chiropractic research journals.

        I still recommend you speak with a chiropractic research department. Perhaps even make a trip to a school to see the circula. You’ll also find we have many MD’s as professors and patients. Not to mention all the hospitals (including Cancer Research Hospitals) that are employing DC’s now.

        Best of luck to your patients Dr. Ernest. I’m not here to to separate the two professions more but to help build a stronger bridge between the two.

        Cheers,
        -ChiroStudent

        • 1) research is not necessarily sham controlled trials.
          2) generating funds is the duty of those who make therapeutic claims, i.e. chiros.
          3) who tells you that i have not had access to chiro res depts?
          4) i do not treat patients and only did research for the last 20 years.
          5) some time you might want to spell my name correctly.
          6) building bridges might require more knowledge than you seem to have.

        • have you thought about answering my questions before issuing further nonsense? after all, i think, you challenged me for doing something “borderline illegal”. would you like to comment what might be illegal about exposing what seems to be highly unethical behaviour of a professional chiro organisation?

    • As a student of Chiro, perhaps you con provide a link to any long term study showing the effectiveness of chiro in eradicating lower back pain.
      Thanks

    • The various chiropractic trade associations have an agenda that compels them to present a certain face towards the public. In the US, they are trying to get chiropractic recognised as a primary care profession – this is for commercial reasons related to Obamacare.

      But we have already seen that the face they present is a false one. Scratch the surface and you find if not an endorsement then certainly a tolerance of “straight” chiros with their false subluxation theory, a blind eye turned to unethical practices such as antivaccination activism, unnecessary X-rays, bogus diagnostic techniques, and of course the whole business of “maintenance adjustments”, chiropractic’s cash cow.

      In short, it does not mater what they say because their statements are in the context of a self-serving agenda. What matters is what goes on in chiropractors’ offices around the world – which includes a lot of outright quackery.

      I’d be delighted if yu could show credible independent evidence of meaningful change within the trade, but I am not hopeful that such evidence will be forthcoming.

  • “Neck manipulation has been linked to neurological complications such as strokes – in 1998, a 20-year-old Canadian woman died after neck manipulation caused a blood clot which led to stroke. We would strongly recommend physiotherapy exercises and osteopathy ahead of chiropractic therapy because they are at least effective and much safer.”

    I haven’t read, nor have I bought the book, so forgive my ignorance here when I ask a few questions here.

    1) Association is not causation – can we say with 100% certainty that the neck manipulation was the cause of the clot which then led to the stroke?
    2) Was the neck manipulation performed by a chiropractor, an osteopath, a physiotherapist, a healer that sits in one of those little kiosks at the mall?
    3) What manipulative techniques were used? Was it a rotatory adjustment, was there rotation and extension? These questions might seem trivial, but they are important because they can form a guide as to what techniques are in fact dangerous and could potentially form guidelines for safer practice.

    As a commentary, the siege mentality of this peak body is not exclusive. It happens in countries whenever somebody questions chiropractic. In Australia, one representative body got itself into a lather when chiropractic funding was called into question, emailed it’s members it’s response and also got in a huff when the magazine and newspaper didn’t print their response in it’s entirety. The other peak body did not pay it a moment’s notice and continued their push for their members to a) actively participate in scientific research in the field of chiropractic and b) actively encourage it’s members to follow an evidence based model.

    Which one would you rather be a part of?

    • 1) 100% certainty does rarely exist in biological systems.
      2) strong suspicion of a causal link is sufficient for applying the precautionary principle.
      3) by far the most of the complications after neck manipulations are associated with chiros.
      4) rotational manipulations are most frequently implicated.

  • I stand incorrect. I’ve spoken with my professor and what you stated above is opinion. Therefore I apologize. The reason I stated something to begin with Dr. Ernst was about the following comments:

    Guy Chapman stated: “I can see absolutely no justification for chiropractic being allowed to continue.”

    And then you followed it by stating he had a good point. In this case it’s an opinion and not slander or a part of a solicitation act.

    Anti-vaccination is not taught in Chiropractic Schools. The our governing bodies like the ACA show support of vaccines. DC’s that do not follow these guidelines are doing it on their own terms.

    I have a fair deal of knowledge, thank you. I’m confident in my career choice, and absolutely can’t wait to get out and help people. Even against these longstanding anti-chiro movements. This is the best profession ever and I want more to see that.

    Julian, here’sa good place to start:
    http://www.acatoday.org/level3_css.cfm?T1ID=13&T2ID=61&T3ID=150.

    If you’d like more just let me know.

    • Chiro Student said:

      The our governing bodies like the ACA show support of vaccines.

      ACA Public Policy on vaccination:

      Resolved, that the American Chiropractic Association (ACA) recognize and advise the public that: Since the scientific community acknowledges that the use of vaccines is not without risk, the American Chiropractic Association supports each individual’s right to freedom of choice in his/her own health care based on an informed awareness of the benefits and possible adverse effects of vaccination. The ACA is supportive of a conscience clause or waiver in compulsory vaccination laws thereby maintaining an individual’s right to freedom of choice in health care matters and providing an alternative elective course of action regarding vaccination. (Ratified by the House of Delegates, July 1993, Revised and Ratified June 1998).

      Hardly a ringing endorsement of a treatment that has saved countless lives and reduced or eliminated the suffering of billions of children now is it?

      • There is more to improvement of health over the decades and centuries than progress in medicine, though vaccinations are an important contributor.

        To a large extent the American Chiropractic Association quote about vaccinations, to which you refer, describes the situation as it actually is, rather than kow-towing to mainstream dogma.

        As with virtually everything else we do, engage in, vaccination involves risk and a balance of risk judgement, neither of which are easy to define, or assess. From what I have read and understand, I believe the balance of risk is in favour of vaccination, though the odds would be better with separate vaccines than the combined version.

        One of our granddaughters suffered a febrile fit five days or so after a vaccination, the staff at the hospital to which she was taken being of the opinion that was the most likely cause.

        Being in a multi-storey car park with y wife and, suddenly, finding a child in our care, not just pale but white, extremely still and barely breathing, in her seat, then having to make an emergency ‘phone call and take her to the ambulance at the entrance because that is the furthest it could get, following the ambulance, with our granddaughter on my wife’s lap in it, to the hospital, calling her mother away from work, etc., etc., is not the most gentle experience. The absolute risk of a febrile fit, is, apparently one, or two, per thousand doses (http://www.medicine.ox.ac.uk/bandolier/booth/Vaccines/MMRfebse.html).

        Febrile fits are poorly understood (http://www.nhs.uk/Conditions/Febrile-convulsions/Pages/Causes.aspx), though the all-knowing types may well have a different view from the NHS; is there much they do not know?

        The chances of there not being other potential side effects are, I would have thought, negligible. So, it does come down to persuading people that the balance of risk is in favour of vaccination and talking down to people is not the way to do it. That is very basic psychology but those of a certain persuasion seem to have as little knowledge of psychology as they do of many other subjects and seem more interested in parading their supposed knowledge and equally supposed superiority, rather than actually communicating with people in a reasonable manner. I am well aware that they will always be “right”, regardless, at least compared with anyone else, anyone of a different opinion, view, or knowledge set.

        • It is a stable feature of believers in quackery that they claim science and medicine are “dogmatic”. This is a reversal of the reality.

          Science, including medical science, goes on the evidence. Generations of doctors causally assumed that ulcers were caused by stress, this was overturned rapidly by credible experimental evidence demonstrating that the real cause of most ulcers was helicobacter pylori. Antibiotics are now the standard of care for duodenal ulcers, and it works.

          Chiropractic, like most alternatives to medicine, lacks any mechanism for discarding wrong ideas. This is an inevitable consequence of its being based on unverifiable concepts. A chiropractor cannot objectively test whether spinal subluxation causes disease, because there is no objective test for subluxation and chiros faced with the same patient will routinely diagnose different subluxations. In the absence of any credible evidence it exists, and any objective measurement that can be used to test it, there is no way of settling questions around it. Disputes are addressed either by reference to the founding texts, or by simply disagreeing. Exactly like a religion, in fact.

          As to the rest of it, febrile seizures are alarming but rarely serious. http://www.nhs.uk/conditions/Febrile-convulsions/Pages/Introduction.aspx

          Smallpox killed roughly half a billion people in the 20th Century before it was eradicated by vaccination. How many Western hospitals currently have polio wards? Death rates from measles and pertussis have also plummeted following widespread vaccination.

          Of course the consequence of this is that we have largely forgotten, as a population, what a scourge these diseases are. And that results in false comparisons of vaccination with no vaccination in the context of a largely vaccinated population. As we are seeing right now in Wales, this breaks down as soon as the population vaccination level starts to dip.

          Like it or not, vaccination saves lives. Millions of lives. It takes, as far as the evidence goes, very few.

          Parents who are genuinely worried about their children’s long term health should give up driving. That is the number one cause of preventable death in children, as far as I can tell.

      • Looks like it’s not just the USA that has chiros who are, shall we say, somewhat ambivalent, to the benefits of vaccinations:

        The Chiropractors’ Association of Australia: the compulsion of anti-vaccinationism

    • There aren’t any references to long term studies of chiro in relation to lower back pain there. Have any such studies been done to your knowledge?

    • “[Chiropractic] is the best profession ever”. Crikey, your professors have made an impact haven’t they!?

    • Let me unpick my “good point” for you and see if you can understand why there is absolutely nothing defamatory about it.

      1. There is no credible evidence that chiropractic is more effective than other forms of manipulation therapy (and no reason to expect it would be).
      2. There are documented and very serious adverse effects. Not just chiropractic stroke, also the use of unnecessary whole-spine X-rays, for example.
      3. Chiropractic comes with baggage including anti-vaccination nonsense, pseudoscience and exploitation ( the “maintenance adjustment”).

      It seems to me that an ethical individual cannot in good conscience operate like that. It seems to me that the correct course for an ethical individual would be to retrain as a physiotherapist, widening their skills and moving away from the dangerous, unethical or downright bogus practices.

      And the more people understand the issues with chiropractic, the more of a problem it’s going to be. Doctors are going to be more and more reluctant to refer people to someone who might not just try to talk their patients out of vaccination, but may actually kill them.

      Worse, people reviewing the field preparing to study will also increasingly be made aware of the questionable nature of chiropractic. New entrants with a strong sense of ethics or with a penchant for science and evidence, will not join. The only new joiners will be people who do not care about science, do not care about ethical issues, and often are seduced by the promise of income (a major feature of chiropractic continuing education). Subsidised funding for degrees will not support these students. Most courses will be (already are in the UK) in private colleges, and will run up a debt that further reinforces the profit imperative. Engineers call this self-reinforcing situation “positive feedback”, and it is a very bad thing because it inherently drives towards extremes.

      So it’s going to get worse before it gets better. It won’t be long before the only chiropractors in practice are the frauds and charlatans. Better to shut it down now while the members of the profession still have at least some remaining dignity.

  • JR: i posted 3 publicastions but i don’t know what happened so here they are again.

    Manipulative therapy versus education programs in chronic low back pain.
    Triano JJ, McGregor M, Hondras MA, Brennan PC.
    http://www.ncbi.nlm.nih.gov/pubmed/?term=manipulative+therapy+versus+education+programs+in+chronic+low+back+pain

    Dose-response for chiropractic care of chronic low back pain.
    Haas M, Groupp E, Kraemer DF.
    http://www.ncbi.nlm.nih.gov/pubmed/?term=Dose-response+for+chiropractic+care+of+chronic+low+back+pain

    A randomized controlled trial comparing 2 types of spinal manipulation and minimal conservative medical care for adults 55 years and older with subacute or chronic low back pain.
    Hondras MA, Long CR, Cao Y, Rowell RM, Meeker WC.
    http://www.ncbi.nlm.nih.gov/pubmed/19539115

    Adzcliff:
    you know i think it’s more the patients then the professors! Having a patient walk in with 5 out of 10 pain and then walk out with about 1 out of 10 is the best. I just want to make sure it’s known that we are not just taught by DC’s but we have MD’s and PhD’s educating us.

    I just feel fortunate to have found this profession and to the opportunity to learn it.

    • Yes these are all short term studies. I think what you’ll find is that chiropractic provides symptomatic relief of lower back pain but doesn’t address underlying causes/problems, so the condition gets worse until eventually the patient has to go somewhere else for effective treatment. The problem is with chiropractic theory that problems with the spine cause problems elsewhere. Actually in most cases the situation is precisely the opposite. Back problems are caused by issues with posture, shortening of tendons, lack of muscle development, obesity etc.

      People will reward chiropractors for temporarily suppressing their pain without asking them to make lifestyle changes like doing exercise or cutting down on the beer. But they are storing up problems by doing so. I think you should take care to understand the nature of the profession you are training for, and not have any illusions that you are going into a useful branch of medicine.

      • Actually Julian, quite the opposite – I tell my patients that they need to improve their diet, or exercise habits. A lot of them do not like that aspect of the service that I provide – I think a lot of them come in with the expectation that I will just “crack them and fix them”. A lot of us go into more depth than that and try to get to the root of the problem, not just symptomatic relief of their pain. A lot that I know, anyway.

        • If you diagnose the cause of the problem and propose a specific regime to address it, you are doing physiotherapy. I’ve seen a lot of chiropractors, and a few physiotherapists, so I’m not under any illusions about how the two professions operate. NB I’ve only had to see a few physios because they gave me the tools to self treat and keep myself problem free; the chiros just kept me coming back.

          • I disagree on the nomenclature, but either way I’m doing the right thing by the patient.
            Despite most definitions of chiropractic containing the term subluxation, it’s still possible to practice chiropractic without mentioning the S word & not simply be called a physio.

          • Julian I’m sorry for not seeing your post earlier!

            Matt thanks for support!

            The first thing I thought when I read your post was “WHAT!?”. When I take a patient through care at the school we work in phases. Acute, Subacute, and Chronic. The acute phase of care is about pain supression, proper lifestyle changes, and proper posture (this includes adjusttments and physical therapy modalities like ultrasound, estim, etc). Subacute phase is to maintain low pain and introduce physical therapy exercises to create stability. The chronic phase is physical therapy, at home therapy with adjustments. Our goal is to get them to Maintence/wellness care which is to see the patient 1x a month to 1x every few months.

        • Matt, you seem to be a nice person who actually cares. Please retrain as a physiotherapist. This will allow you to deliver all the benefits of manipulation, plus additional benefits, and will free you of the tiresome necessity to defend your profession against the charlatan majority who give the minority like you a bad name.

          The core concept that distinguishes chiro from physio is the concept of subluxation. This is pseudoscientific claptrap. Take that out and you have basically, manipulative physiotherapy.

  • Chiro Student wrote: “Having a patient walk in with 5 out of 10 pain and then walk out with about 1 out of 10 is the best.”

    I have no doubt that that is a very rewarding experience for you, but it may not be due to anything specific that you have done. I fear that it is unlikely that you would be able to recognise self-serving biases. IOW, you would, somehow, have to eliminate the placebo effect (enhanced by touch), demand characteristics (e.g. your customer is unwilling to admit to having experienced a poor outcome if a great deal of time and money has been invested), and the possibility that the allegedly relieved symptoms may have been psychosomatic to begin with.

    • Blue, you’ve got a good point. I can totally see where you’re coming from but I think I can refute that with how we conduct our care here.

      Here we take a Subjective note first consisting on their pain levels now and since last patient visit. We want to know the types of pain felt (eg. dull, sharp, burning, etc) because it helps describe the tissue affected, the depth of pain (superficial, deep), when it began, and what agravates & relieves the area (eg. right rotation, trunk flexion, etc). We ask many more questions (family history, social history, etc) but for the sake of this question i’ll keep it to that.
      Then we take an Objective note, which consist of me objectively doing the following at evaluation: palpating the patients joints and muscles searching for restrictions and tonicity. I’m feeling for mild, moderate, or severe hypertonic/hyptonic in muscles. I’m also feelign for things like, can C1 on the left side, rotate to the right similiar to how C1 on the right side can rotate to the let. To what angle/degree can the patient rotate, laterally flex, flex, ext? Then I observe posture, looking things like shoulder hiking, hip hiking, etc. Next I’ll, conduct ortho’s like, Jacksons compression test, seated and standing Kemps, etc. Then I’ll make the patient do certain movements ( eg. hip extension, hip abduction, trunk flexion). Here i’m looking for how the part moves through the correct plane line, plus if there’s proper firing of muscles in the corret order. If there isn’t, then there could be improper compensatory muscle reaction that needs care.

      So in effort to be sure the patient is actually responding to care, and not just saying ” i feel better” because I touched them or cause they paid. I compare my objective findings before and after a treatment plan. I’ll recheck all the positive findings that I found in the Objective and compare the results before and after. Stuff like can the C1 rotate right and left equally? Have we increased range of motion (active, passive, and resistive)? How has the tonicity of the muscle changed? Does the patient still have positive ortho’s? Does the patient have proper firing of msucles now during movement patterns (hip abduction, trunk flexion, etc).

      • and it does never occur to you that you may be the victim of observer bias?

        • so you’re essentially saying I’m creating results to make my care appear favorable. correct? Much like how a pharma company will retest a Statin to make it appear favorable.

          If so, Objective findings is sceience and you expect the the researcher/physician to report truthful data. That’s something everyone has to live with. So where do draw the line? And what do you suggest I do to make objective findings more scientifically relevant in your eyes?

      • most of these “objective” tests are all but objective.

    • Indeed. I would like to add that Chiro Student is, perhaps, in desperate need of fully understanding terms such as: critical thinking skills; regression to the mean; the power of the placebo and nocebo reactions; the timeless efficacy of the sales technique often known as purging; the art of deception (the JREF is an excellent resource); the logical fallacy of the appeal to authority; and the plethora of cognitive biases associated with the most easily deceived person on planet Earth: me, myself, I.

      I admire everyone who dedicates themselves to their profession and I sincerely hope that Chiro Student and many other students will become so dedicated to their work that they will eventually realize it is far better to seek both evidence- and science-based knowledge via asking questions phrased with humility rather than criticizing those who have dedicated their lives to reduce human suffering.

      • critical thinking by a chiropractor taught in a chiro college? that’ll be the day!

        • Dr. Ernst:
          Yup we learn how to do amongst many trimesters but the best one ( i believe) that puts all of our knowledge to the test begins in trimester 7 of 10 when we begin student-clinic.

          • in this case, why don’t you display some (self)-critical thinking?

          • Haha, yeah sure

            Recently, I had a new patient that came in with left hip pain as her main complaint. She’s in her 60’s, 5ft, ~125lbs, was diagnosed with SLE in the 80’s, and has scoliosis (she couldn’t recall the angle though). She takes multiple medications, including long term use of prednisone. She pointed to her left glut and stated it began about 3 weeks ago. She described it as a local, dull ache pain that felt deep. Pain is always there but when she leans to the left (left lateral flexion) the pain increased. Pain did not radiate or refer from this point and the patient has not had this before. Patrick-FABERE on left hip was positive local deep pain. Active and Passive ROM with the patient supine did not aggravate the area, but a resisted psoas did. The patient could not conduct a heel-shin test. Mennell’s test on the left was positive to for glut med. I asked her if she had been sick lately and she stated that in Jan she was. Her PCP did a chest xray and diagnosed her with pneumonia and a rib fracture. Joint play of the left hip felt equal bilaterally but her left ilium was rotate posteriorly, which gave her a functionally short left leg and pain superior to her left PSIS.

            The first thing I did from here was Xray her hip and cervicals. She has been on prednisone for a prolong period of time, which can cause channdlers disease (avascular necrosis of the adult femoral head), or she could have osteomyleitis of the femoral head (although this was less likely since she was sick a few months ago). I took films of her neck because lupus can disrupt the atlantotransverse ligament so I needed to check her ADI incase we were going manually adjust.

            I took the films yesterday and have not sat down to interpt it just yet. However, I did glance at the films and it appeared to have no osseous evidence of pathology in her femoral head, which has shifted my diagnosis more towards myalgia of the glut med (because of a positive mennells), and intersegmental disfunction of her left ilum (due to the left posterior ilum and pain with resisted psoas). Her cervical xray appeared to have a normal ADI during flex/ext films so she’s cleared for manual. However she may be osteopenic which would change this. If the radiologist here determines she is then I will do activator instead of manual. Activator is a instrument assisted tool that can fire an impulse. It requires no twisting or turning of the patient therefore geriatric patients & patients that have anxiety or fear of manual adjustment can still get the care they need.

      • Pete could you please explain how I lack an understanding in those… You have no idea what my background is in plus probably have no idea of the prerequisites to get into Chiro school and what’s taught at the accredited schools here..

        Here in the states we’re creating more evidence (for and against) for Chiropractic and using that to drive a evidence-based care. In fact just yesterday we were discussing Chiropractic care and infantile colic and how there’s research on both sides of the story.

        • Chiro Student: I could indeed give an in-depth explanation, however, it would be totally inappropriate in this arena to write a multi-page reply.

          You wrote “You have no idea what my background is in plus probably have no idea of the prerequisites to get into Chiro school and what’s taught at the accredited schools here.”, which more than adequately demonstrates your lack of critical thinking skills.

          Try applying what you wrote in reverse: You have no idea what Pete’s background is in and your assumption that Pete has probably no idea about the prerequisites and course content of “Chiro school” guarantees that Pete will neither bother to enlighten you nor bother to argue with you.

          In patient care, there is a very distinctive line between competence and arrogance. Unfortunately, you have already crossed this line.

  • i am beginning to wonder what the numerous comments of chiro student have to do with the subject of this post, i.e. BCA doing odd things, and whether his verbal diarrhea is merely a strategy to distract from the real subject. CHIRO STUDENT: do you have anything relevant to say about the subject of this post; please read the ‘rules’ of this blog.

    • Dr. Ernst,
      The reason I got invovled was due to the comments here, not the BCA article. I’ve been respectful, and timely with my responses. And the individuals here, including you, have asked questions which I’ve tried to answer but apparently all I’ve done is just wasted my own time and energy. I recently answered your question about displaying self critical thinking and instead of addressing that I did or did not; you insult me again and change the topic.

      Blue Wode,
      I’m not answering any more questions since, according to Ernst, I’m full of verbal diarrhea. At least I’m trying to have a polite debate here. Best of luck Blue!

      • this is such a familiar technique of alt med proponents: they all too often talk rubbish, rubbish and more rubbish. once one points it out in unmistakenly clear terms, they say “huuuuh you insulted me, this goes to show that you are in the wrong”

        • luckily anyone who wants can roll the threat back and see that the very first comment of CHIRO STUDENT was 1) not on subject 2) already “insulting” [poisonous thoughts are worse than verbal diarrhea, in my view]. then we had plenty of patience with him – but at some point, even my patience runs out.

  • Chiro Student wrote on Thursday 11 April 2013 at 15:23 : “Activator is a instrument assisted tool that can fire an impulse. It requires no twisting or turning of the patient therefore geriatric patients & patients that have anxiety or fear of manual adjustment can still get the care they need.”

    Sadly, it looks like that “care” is just an expensive placebo…
    http://www.scienceinmedicine.org.au/images/pdf/revchirodev.pdf

    Returning to the topic of Prof. Ernst’s blog post, chiropractor cult-like behaviour, the BCA recently implied that that it was aware of robust evidence to support its assertion that some authors who were extremely cautious about neck manipulation had cherry picked low quality evidence:
    http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/2132-response-from-authors-of-bmj-article-opposing-neck-manipulation.html

    As the BCA still hasn’t produced that robust evidence, would any BCA members like to take the BCA to task for that failure in the comments here?

    Here, BTW, is the BCA’s penchant for cherry-picking:
    http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/2130-the-british-chiropractic-association-experts-in-cherry-picking.html

  • It’s interesting to go thru Chiro Student’s case discussion – the elderly woman with hip pain.

    I’m not aware of SLE disrupting the atlanto-axial ligament – that’s rheumatoid arthritis.

    Osteomyelitis of the femoral head in an elderly woman would be accompanied by severe sepsis.

    Pain in the buttock is not of hip joiont origin – hip joint pain is found in the groin.

    But CHiro Student thinks he/she knows quite a lot, actually….and hasn’t even started clinic yet!

    • thank you! exactly my impression.
      this is why i suspected his [i think it's a he] verbal diarrhea was meant to distract from the true subject of this post.
      in general, i have found chiros often to be as you describe: clever by half [or less].

      • Sue & Edward

        Sorry for the long delay in responding.

        ADI instability can be caused by: RA, Jefferson Fractures, SLE, and any inflammatory arthritide. Amongst the sero-negative Rheumatoid type, Psoriatic arthritis is the most common.

        Sue: SLE can cause ligament laxity while RA will cause errosions and pannus. You don’t need severe sepsis for a bone infection. The patient said she had hip pain when she pointed to her glut. Hip joint pain does not mean painful groin. Visit some trigger points referral patterns.

        Ed: If you really thought that then you should have said something instead of following it up the way you did.

        I don’t know everything but I know a good amount. Sounds like both of you need to revisit some classes or textbooks. A Chriropactic school might take you as a student if you’re lucky enough.

      • Read Politics in healing by Dan Daley and you will get a true picture of what you promote.

    • real doctors use the term “subluxation” for a phenomenon that is real, ehile chiropractors use it for a figment of their imagination.

      • If by real dr you mean the ones that orecribe drugs to the effect they are the third leadingcause of death and unnecessary surgeries then yes you are correct.

        • He means the ones who save countless lives, reduce endless suffering, make childbirth far safer than it has ever been, prevent deadly diseases and give us a higher quality of life than we have ever had.

      • Is subluxation not a term for spinal joint dysfunction, chiropractors use it in relation to hypomobility and medical people to describe hypo mobility or partial dislocation; correct me if I am wrong.

        • the chiropractic profession has provided us with such an array of nebulous definitions that anyone, it seems, can attach almost any meaning to the term.

          • Yes there are around 100 names for the chiropractic lesion. The term we are talking about is the subluxation a term used by chiropractors and medical doctors to describe spinal joint dysfunctiom, hardly” a figment of my imagination”.

            What causes the confusion is that chiropractors are unable to agree on the physiological theory behind the affect of spinal joint dysfunction. Does it just cause localized pain and inflammation, or is it nerve irritation causing muscle spasm and pain and altered posture, or does the nerve interference affect general health and well being?

          • i think you know quite well that the confusion also extends to the numerous definitions of “subluxation”.

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