MD, PhD, FMedSci, FSB, FRCP, FRCPEd

One would have thought that, after losing their libel case against Simon Singh, chiropractors across the world might have got their act together and stopped claiming that their ‘bogus’ treatments are effective for conditions that lack both supporting evidence and scientific rationale. However, our investigation which was carried out in 2010, well after the libel action and the embarrassing defeat for chiropractors, sadly suggests otherwise.

It was aimed at determining  the frequency of claims of chiropractors and their associations to treat a range of pre-defined conditions: asthma, headache/migraine, infant colic, colic, ear infection/earache/otitis media, neck pain, whiplash as examples of indications not supported by sound evidence, and lower back pain as an example of a condition supported by some evidence.

For this purpose, we conducted a review of 200 websites of individual chiropractors and 9 websites of chiropractic associations from Australia, Canada, New Zealand, the United Kingdom, and the United States between 1 October 2008 and 26 November 2008. Our outcome measure was either direct or indirect claims regarding the eight above-named conditions.

We found evidence that 95% chiropractor websites made unsubstantiated claims regarding at least one of these conditions. Four of the 9 (44%) associations made justified claims about lower back pain. All 9 associations made unsubstantiated claims about headache/migraine. Unsubstantiated claims were also made about asthma, ear infection/earache/otitis media, neck pain.

We concluded that the majority of chiropractors and their associations in the English-speaking world seem to make therapeutic claims that are not supported by sound evidence, whilst only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue.

Criticism regarding unsubstantiated claims have been raised even from within the profession of chiropractors (albeit very, very rarely); two chiropractors suggested that they are “evidence of a lack of professionalism and of quackery” that have evolved within a “tradition of dogma, fallacious reasoning, and unconventional attitudes about research and science”. I quite agree; instead of self-critical attitudes, chiropractors seem to develop a pathological state of denial.

The codes of ethics of chiropractors vary, of course, from nation to nation, but they tend to agree that information used must be factual and verifiable and should not be misleading or inaccurate. Unsubstantiated claims such as those disclosed by our investigation thus violate the rules of these codes. More importantly perhaps, they also misinform unsuspecting consumers and put public health at risk. This has now been going on for such a long time that it truly is embarrassing – not just for chiropractors (who seem to be immune to embarrassment) but to regulators and even to society at large who tolerates such abuse at the hands of the chiropractic profession.

Considering more recent events in the realm of chiropractic, it seems highly unlikely that the situation is going to improve any time soon. Misinformation in the name of maximising income , it often seems to me, is what chiropractic is really about.

27 Responses to Drowning in a sea of misinformation. Part 4: chiropractic professional organisations

  • It’s been my view for some time that we will be able to trust health regulation the day the last homeopath is driven out of Britain, but the case against chiropractors is probably more compelling: there is no credible evidence of any effect over and above evidence-based manipulative therapies, a steady trickle of serious adverse events, and a strong undercurrent of anti-medicine, anti-vaccination nonsense that is actively hazardous to public health.

    Perhaps I should revise my litmus test: we will know that regulation of medicine is adequate when there are no more chiropractors. Those who are ethical and sincere (and I do not doubt that there are some) can easily re-train as physiotherapists.

  • that test, I fear, will never indicate adequate regulation. chiros (and osteos) are regulated by statute in the UK. we know that does not mean adequate regulation but it means the professions are considered to be established. this is the biggest danger of regulation of alt med professions: hence forward they continue as before but they enjoy their new status and the fact that hardly anyone will voice criticism. this is why I so often state THE REGULATION OF NONSENSE WILL RESULT IN NONSENSE

    • Professor Ernst wrote: “Chiros (and osteos) are regulated by statute in the UK. We know that does not mean adequate regulation but it means the professions are considered to be established. This is the biggest danger of regulation of alt med professions: hence forward they continue as before but they enjoy their new status and the fact that hardly anyone will voice criticism. This is why I so often state THE REGULATION OF NONSENSE WILL RESULT IN NONSENSE.”

      Perhaps not surprisingly, it looks like Prince Charles helped to push forward the statutory regulation of chiropractors in the UK…
      http://www.ecupresidentblog.com/2012/12/the-pursuit-for-legislation-iii.html

      As a consequence, it saw the profession unite under a group formed specifically to pursue regulation and secure the Chiropractors Act (1994). According to the Chairman of the GCC at the time, this happened “in spite of strong mutual suspicion and distrust”. The Chairman also claimed that regulation for the profession would “literally ‘legitimise it’, establishing its members within the community, making them feel more valued…in turn bringing greater opportunity for more clients and a healthier bank balance”:
      http://web.archive.org/web/20060924183943/www.ejom.co.uk/backissues/vol2no6/feature1.html

      Fortunately, the Nightingale Collaboration, a fairly new activist organisation which combats false health claims, has recognised that the regulation of chiropractic in the UK was premature, and has offered a solution to the problem via its response to the recent Consultation on the Regulation of Health Care Professionals:

      Summary
      “Statutory regulation rightly confers respectability and trustworthiness in the eyes of the public and these need to be protected to maintain that trust. For chiropractic and osteopathy, we do not believe statutory regulation is deserved or necessary and it gives a false imprimatur that misleads the public. Because of this, our overall view is that statutory regulation of chiropractors and osteopaths is not appropriate and recommend that this statutory regulation be abolished. We believe that adequate protection of the public can be achieved by existing regulations (such as The Consumer Protection from Unfair Trading Regulations 2008) as are applied to any other alternative therapies and businesses.”
      http://www.nightingale-collaboration.org/images/stories/documents/Regulation_of_Health_Care_Professionals.pdf

      Does anyone know the procedure for abolishing statutory regulation of a profession?

      • Much of early work was done at dinner parties (Lord Kindersley, HRH Prince Charles, Royal Society of Medicine, Royal College of Surgeons, General Medical Council – but not the BMA, which is the trade union for the medical profession in the UK). Prince Charles recommended that the chiropractors approached the Kings Fund. Ian Hutchinson lobbied the Kings Fund for a working party and refused to support Osteopathy Bill unless such a working party was set up.

        I did not know that in such clear terms; but it makes sense.
        thanks for pointing it out to us.

  • Out of interest what qualifications would a chiropractor have that would enable them to qualify as a physiotherapist? As I far as I know physiotherapy requires completion of a degree course to be able to join the register and I’m not sure that chiropractic training/experience would help.

    • They might have some basic anatomy (I’ll look at Palmer Chiro College – US), but mostly I think what is meant by this suggestion is that PT would be an area a chiro might be interested in RE-training for–I would only want this to happen if said chiro has been thoroughly purged of his/her altie leanings!.

  • Professor Ernst wrote: “The codes of ethics of chiropractors vary, of course, from nation to nation, but they tend to agree that information used must be factual and verifiable and should not be misleading or inaccurate. Unsubstantiated claims such as those disclosed by our investigation thus violate the rules of these codes.

    Sadly, the regulators – who are supposed to enforce these codes of ethics – are often just as bad when it comes to unsubstantiated claims. With regard to the UK’s General Chiropractic Council (GCC), the following are on record:

    That craniosacral therapy and applied kinesiology both fall within its definition of evidence-based care:
    http://jdc325.files.wordpress.com/2009/06/gcc-ak.pdf

    That its expert witness claimed that [mythical] chiropractic ‘subluxations’ were “commonplace to the point of universality in patients. See p.13 here:
    http://www.gcc-uk.org/files/link_file/FITNESS_TO_PRACTISE_REPORT_2007_FINAL_FOR_WEBSITE.pdf

    That it implies that [mythical] chiropractic subluxations are linked to ‘health concerns’ without providing any evidence:
    http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1825-subluxations-still-no-evidence.html

    – NB. the implication in the link above was the result of pressure place on the GCC by the subluxation-based Alliance of UK Chiropractors, an organisation which claims to represent the majority of chiropractors in the UK:
    https://images.vortala.com/chiropractor/England/United%20Kingdom/United%20Kingdom/PP1742_UCA_Assoc_Prem/documents/AUKC_Oct_Newsletter.pdf

    Professor Ernst wrote: “Misinformation in the name of maximising income, it often seems to me, is what chiropractic is really about.”

    I don’t think there’s any escaping that impression now. Indeed, 20 years ago, Quackwatch’s Stephen Barrett (MD) wrote a very perceptive piece on the subject of chiropractors and vested financial interests in the ‘Spine Salesmen’ chapter of the book, ‘The Health Robbers’:

    Quote
    “If a chiropractor limited his practice to musculoskeletal conditions such as simple backaches, if he were able to determine which patients are appropriate for him to treat, if he consulted and referred to medical doctors when he couldn’t handle a problem, if he were not overly vigorous in his manipulations, if he minimized the use of x-rays, and if he encouraged the use of proven public health measures, his patients would be relatively safe. But he might not be able to earn a living.”

    In other words, chiropractic is a house of cards that is currently being built higher and higher…

    • It’s shocking that chiros are allowed to use x-rays at all, let alone indiscriminately. I honestly didn’t realize they do this until I started reading blogs. Here in the US, x-ray tech is a specialty that requires about three years (if prerequisites in science are met) of coursework and they only work in clinical settings where they are supervised (not sure how rigidly) by MD’s.

  • I am slightly confused by you comments Prof Ernst in particular when you state “..our investigation which was carried out in 2010, well after the libel action” yet your research was actually conducted in 2008 and only published at this later date. I believe that the libel action was in fact concluded much later than this when the chiropractors withdrew their claim as opposed to loosing it as you state.

    Since your post is about misinformation you may wish to comment on the quality of the evidence that you have used to form your opinion.

    • sorry, I should have made this clearer; our research was started well after the BCA had started suing Simon. arguably chiros should have known even before that the evidence for their claims is bogus; it is not up to others to show that claims are bogus; it is up to those who make claims to ensure they are evidence-based. once the BCA had started the libel case, chiropractors aroud the world knew that they were disputed and should have scrutinised them – don’t you think?

  • Our provincial chiro organization has run a series of very clever, funny ads about the “everyday stuntman” http://www.youtube.com/watch?v=WhrqoBYa4SE

    and then claims that more than 50% of Albertans have seen a chiro. I can’t believe that. Several of our local chiros actively advertise against vaccination, so when our provincial government added chiropractic coverage for seniors in the last health budget, I wrote my first letter to the government. The ironic thing was that the government home page for seniors health was all about the importance of the flu shot – I pointed out how chiropractors as primary care would no doubt lower our already low vaccination rate. I even sent them a copy of the propaganda material that the chiros are handing out, as well as the position statement from the Alberta College and Association of Chiropractors regarding vaccination (scroll down) which you can see is along the lines of “it’s not in our scope of practice but we encourage our chiropractors to discourage it anyway”. http://www.albertachiro.com/sitewyze/files/ACAC_Position_Statements.pdf

    I just noticed that they were regulated under the Health Professions Act as well. It’s a conflict to be both a college and an association. Our provincial pharmacists’ group splintered into 2 separate groups several years ago for that reason. So if you make a complaint to the ACAC, they will be more likely to defend their member than fairly assess the complaint.

  • Edzard, just inform you that you have been given a title of an extremists with a biased perspective by your own profession in International Journal of Clinical Practice 2013;67(9):825-833

    http://www.medscape.com/viewarticle/809688

    It’s about one of your favorite subject of Chiropractic adverse events. Even your own profession is aware and admit of your biased opinions. Do you agree with your colleagues? Who with you are fighting with after all? Truth? Science?

    Jani Mikkonen

  • Professor Ernst you state, “One would have thought that, after loosing (sic) their libel case against Simon Singh, chiropractors across the world might have got their act together”. I struggle to see how this comment is relevant when the Singh decision was made in 2010 and the review looked at over 200 websites between 1 October 2008 and 26 November 2008 – over a year before the libel case was settled.

    Perhaps someone needs to review the content of chiropractors’ websites to see if these claims are still actually being made. Being in the United Kingdom I would be particularly interested if any UK chiropractors still claimed to treat the conditions you name above (and if the majority don’t perhaps you shouldn’t tar all practitioners with the same brush).

  • Professor Ernst you state, “One would have thought that, after loosing (sic) their libel case against Simon Singh, chiropractors across the world might have got their act together”. I struggle to see how this comment is relevant when the Singh decision was made in 2010 and the review looked at over 200 websites between 1 October 2008 and 26 November 2008 – over a year before the libel case was settled.

    Perhaps someone needs to review the content of chiropractors’ websites to see if these claims are still actually being made. Being in the United Kingdom I would be particularly interested if any UK chiropractors still claimed to treat the conditions you name above (and if the majority don’t perhaps you shouldn’t tar all practitioners with the same brush).

    • good point: someone needs to repeat this study. but after they sued Simon, in 2008, the world of chiro already knew very well that these claims were not kosher. in fact, they should have known before.

  • Having spent some considerable time going in circles at the Palmer website I can say that the best I could find is a “sample curricula”, which is really only a class schedule–and even that seems minimal. There are no descriptions, no catalog, no nothing you would find at any real college or university website. It’s truly pathetic, lots of verbiage saying nothing. Tooth Fairy Science at its best.

    http://www.palmer.edu/Academics/

    • @Irene
      Thank goodness for the internet! You can find out anything you to know or argue about. You’re practically an expert now on chiropractic.

  • The International Chiropractic Pediatric Association (whose motto is Establishing and Advancing the Chiropractic Family Wellness Lifestyle) have just published the following desperate call to action:

    Dear colleagues,

    We are in desperate need of your help. On the 4th of September The Dutch ministry of health ruled that chiropractic cervical adjustments were irresponsible and can cause stroke even though we sent them many studies to the contrary. This is one time we must stand together in defence of our beloved profession. I am asking every chiropractor, chiropractic assistant and anyone else who understands the overwhelming benefit that chiropractic has on the improvement of health to sign and send the attached letter of protest. Please help us put an end to this ludicrous publication and ruling with your personal response. Our goal is to flood there office with a huge response from our great profession and let them know our character can not be tarnished by a few quack busters. We need your help and we need it now.

    Please take 2 minutes of your time and send the letter of protest immediately. Please forward this letter to every chiropractor you know. If enforced this ruling will be devastating for chiropractic all over the world. If you have any questions you can email me at ken@xs4all.nl or call 0031 655 301 543.

    My sincere thanks!

    Ken Koehler D.C.

    The letter they want their supporters to send is this:

    Ministrie van Volksgezondheid, Welzijn en sport,
    t.a.v. de heren dr.P.J.Zwietering en dr. Th. Wijnberg
    Postbus 90700, email: meldpunt@igz.nl en t.wijnberg@igz.nl
    2509 LS Den Haag
    Netherlands

    Dear Sirs,

    We the undersigned vehemently protest your decision on September 4, 2013 stating in your judgment that high cervical chiropractic adjustments are irresponsible.

    Because of your decision and its publication many patients have become unnecessarily concerned and anxious. They may very well be deprived of a procedure that has been deemed safe and effective for many health related problems.

    As you are well aware there is scientific literature proclaiming the safety and effectiveness of chiropractic cervical adjustments and no scientific literature to the contrary.

    We the undersigned ask you to reverse your decision and withdraw its publication so we can avoid legal action. We ask that you take the decision that chiropractic cervical adjustments are safe and effective especially when compared to any medical procedure.

    My emphasis. Unbelievable.

  • I’m confused with your attacks against chiropractors, are physiotherapists not making the same claims? I’ll answer this for you, YES! What about medicine, didn’t the BMJ release a recent report stating majority of medical practices/rx options weren’t researched and most treatments were shown to be ineffective. Why is medical error the #3 preventable killer according to WHO.

  • Kobe said:

    didn’t the BMJ release a recent report stating majority of medical practices/rx options weren’t researched and most treatments were shown to be ineffective.

    Don’t think so. Where do you think you read that?

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