MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

On their website, the ASA yesterday published a statement about chiropractic. It outlines which claims UK chiropractors are allowed to make and which are likely to get them into conflict with the ASA. Here are a few excerpts (my comments are added in bold):

Chiropractic is a healthcare profession that focuses on diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, with special emphasis on the spine. It emphasises manual therapy including spinal manipulation and other joint and soft-tissue manipulation, and includes exercises, and health and lifestyle counselling…

Why not say as it is: more than 90% of patients consulting a chiropractor will receive spinal manipulations. Therefore the best way to define chiropractic is by its hallmark intervention. Using vague language like ‘manual therapy… exercises, and health and lifestyle counselling’ creates big problems and opens the door to all sorts of therapeutic claims (see below).

In 2017 the ASA carried out an evidence review on the use of multi-modal approaches used in Chiropractic in treating sciatica, whiplash and sports injuries as well as the treatment of babies, children and pregnant women as specific patient groups. The subsequent ASA Guidance explains in more detail the types of claims (including phraseology) that are likely to be acceptable for chiropractors to make in their advertising and those which are not.   We recommend chiropractors consider this CAP advice and the ASA Guidance together when making treatment claims in advertising.

Based on all evidence submitted and reviewed to date, the ASA and CAP accept that chiropractors may claim to treat the following conditions:

  • Ankle sprain (short term management)
  • Cramp
  • Elbow pain and tennis elbow (lateral epicondylitis) arising from associated musculoskeletal conditions of the back and neck, but not isolated occurrences
  • Headache arising from the neck (cervicogenic)
  • Inability to relax
  • Joint pains
  • Joint pains including hip and knee pain from osteoarthritis as an adjunct to core OA treatments and exercise
  • General, acute & chronic backache, back pain (not arising from injury or accident)
  • Generalised aches and pains
  • Lumbago
  • Mechanical neck pain (as opposed to neck pain following injury i.e. whiplash)
  • Migraine prevention
  • Minor sports injuries and tensions
  • Muscle spasms
  • Plantar fasciitis (short term management)
  • Rotator cuff injuries, disease or disorders
  • Sciatica
  • Shoulder complaints (dysfunction, disorders and pain)
  • Soft tissue disorders of the shoulder

I am puzzled by this list; for most indications, there is no good evidence at all – unless, of course, we consider chiropractic to consist of ‘manual therapy… exercises, and health and lifestyle counselling’ (see above). But, in this case, the list is still very odd because it would then need to include practically all conditions that can affect humans. Or does anyone know of many diseases that cannot benefit from ‘health and lifestyle counselling’?

…As regulated health professionals, chiropractors may refer to treating specific population groups such as pregnant women, children and babies. However, at present there is a limited or negative evidence base for the effectiveness of chiropractic (here the ASA use the term ‘chiropractic’ not as defined above but as a type of therapy which I think is correct but most chiros object to) in treating conditions specific to those groups, such as colic or morning sickness.

Consequently, references to treatment for symptoms and conditions that are likely to be understood to be specific to babies, children or pregnant women are unlikely to be acceptable unless the marketer holds a robust body of evidence…

And why should this be? Is ‘health and lifestyle counselling’ not effective for these conditions? Clearly it is! So this restriction is illogical.

I think, the ASA got themselves into a major muddle here. The only way to sort it out is to define chiropractic by its main therapy, spinal manipulation, and judge it by the proven risks and benefits of this intervention. (A surgeon will also often give ‘health and lifestyle counselling’, but this does not mean that surgery is indicated for migraine, common cold, asthma etc.)

And if we follow this approach, we instantly see that the ASA list of allowed claims makes no sense whatsoever!

7 Responses to Advertising Standards Authority publish list of allowed claims for UK chiros

  • This is an open invitation to bait and switch. I’m shocked by this departure from good sense by the formerly rational ASA. Has it been infiltrated?

    • It wouldn’t surprise me if the General Chiropractic Council (GCC) – possibly along with the chiropractic trade associations – deliberately hoodwinked the ASA. For example, the following is lifted from the GCC’s September 2017 Council meeting:

      Advertising Standards Authority guidance

      36. The GCC was one of the stakeholders with whom the Advertising Standards Authority (ASA)/Committee on Advertising Practice (CAP) shared its draft revised guidance on the advertising of chiropractic services. The GCC fed back comments about the draft guidance to the ASA/CAP in July 2017, following consideration by the GCC Council.

      37. The CER and the Director of Education, Registration and Standards attended a meeting with the Advertising Standards Authority on 16 August 2017 to discuss next steps in relation to the revised guidance. The timeframe for the consideration of that draft revised guidance by the ASA Council has now shifted to October/November (it was anticipated previously that the ASA Council would consider it during June/July).

      38. In addition, the GCC staff team have been working on a revised version of the GCC’s guidance on advertising that will be issued once the ASA/CAP document has been finalised and published. The intention is to publish a revised version of the GCC guidance is to ensure that it is clear to GCC registrants how the GCC and ASA/CAP’s roles and approaches interact. Council’s comments on the proposed revised guidance will be sought prior to publication. We plan to issue a joint communication/announcement with the ASA/CAP around the date of the publication of the ASA/CAP guidance.

      Ref http://www.gcc-uk.org/UserFiles/Docs/Council%20Meetings/2017/Sept%202017%20open%20papers.pdf

      IMO, if chiropractic was regulated properly it would be destroyed. See:
      http://edzardernst.com/2015/08/chiropractic-spinal-manipulation-placebo/

  • Isn’t the other problem to do with the way that these quackeries seem to be taken at their own valuation, as suggrsted by the language?’Choropractoc’ may well ‘focus’ on anything at all, but surely the word ‘treat’ is problematic and open to double meaning?
    If one treats an injury, or infection. one uses-it’s to be hoped- proven methods.
    Technically, rubbing the patient with strawberry jam may count as ‘treatment’, but it’s hardly the way most people would understand the word.

  • Your additional comments are insightful and logical….however in a world of insanity (Chiropractic) it’s difficult to infuse logic and not have the ASA coming out looking insane…..vs Chiropractic looking logical,
    At least in my experience only half of Chiros use manipulation on ‘everyone’, the rest use the other ‘fraudulent adjusting implements & theatrics’. Perhaps a benefit to the public since those theatrics are less deadly.
    Chiros NEED to explain WTF ‘diagnosis of musculoskeletal problems’ means (to them) if NOT subluxation- and it’s myriad nonsensical “tests”? There is NO diagnostic prevalence for 99% of Chiro-treated conditions…they ‘guess’ then over-treat based on their sub-par, dogmatic education, entrepreneurial bombast and powerful financial motivations….then claim moral high-ground since ‘more people die in hospitals than in Chiropractic clinics’….

  • Practically every item in this list describes a mostly self limiting condition.

  • I’m struggling to understand this statement: “As regulated health professionals, chiropractors may refer to treating specific population groups such as pregnant women, children and babies.” I don’t see why statutory regulation should mean that chiropractors are allowed to refer to treating patient groups for which there is a lack of evidence for all of the common conditions. Babies, for instance, don’t (usually) have ANY of the conditions on the “allowed” list above so why are chiropractors allowed to refer to treating them? They gave similar guidance to osteopaths previously which has resulted in a grey area where osteopaths advertise treatment for babies but without saying what they are treating. The reality is that they must be treating common infant conditions for which there is no evidence of effectiveness. This leaves the general public open to continued exploitation.

    • @ compandalt

      I’m struggling with it too. For example, claims that are likely to be acceptable include:

      • Chiropractic is a gentle treatment suitable for children and babies
      • Chiropractic techniques are suitable for children at all stages of development; I will assess your child to see what might help
      • We are proficient in gentle techniques suitable for babies
      • Techniques used on babies and children are delicate, careful and always tailored for the individual
      • The treatment for babies and young children is modified using a slight pressure (sustained release) most commonly rather than the manipulative technique used on adults

      Yet claims that are unlikely to be acceptable include:

      • Our spinal and cranial techniques improve the function of your child’s spine, nervous system and cranial system

      Ref https://www.asa.org.uk/uploads/assets/uploaded/5d8fb69e-5d22-445d-9f83c26b7a1a12d7.pdf

      So what can chiropractors legitimately ‘treat’? With the scope of practice of a registered UK chiropractor not defined either by law or in the GCC’s Code of Practice, and the GCC’s definition of evidence-based care (clinical practice that incorporates the best available evidence from research, the expertise of the chiropractor, and the preference of the patient) allowing for chiropractors’ own beliefs and values to potentially prejudice patient care, what the public really need are laws that: 1.) dramatically curtail claims that chiropractors can make, and 2.) dramatically curtail treatments that chiropractors are permitted to offer.

      But, of course, that would wipe out their livelihoods.

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