The purpose of this paper by Canadian chiropractors was to expand practitioners’ knowledge on areas of liability when treating low back pain patients. Six cases where chiropractors in Canada were sued for allegedly causing or aggravating lumbar disc herniation after spinal manipulative therapy were retrieved using the CANLII database.

The patients were 4 men and 2 women with an average age of 37 years. Trial courts’ decisions were rendered between 2000 and 2011. The following conclusions from Canadian courts were noted:

  1. informed consent is an on-going process that cannot be entirely delegated to office personnel;
  2. when the patient’s history reveals risk factors for lumbar disc herniation the chiropractor has the duty to rule out disc pathology as an aetiology for the symptoms presented by the patients before beginning anything but conservative palliative treatment;
  3. lumbar disc herniation may be triggered by spinal manipulative therapy on vertebral segments distant from the involved herniated disc such as the thoracic spine.

The fact that this article was published by chiropractors seems like a step into the right direction. Disc herniations after chiropractic have been reported regularly and since many years. It is not often that I hear chiropractors admit that their spinal manipulations carry serious risks.

And it is not often that chiropractors consider the issue of informed consent. One the one hand, one hardly can blame them for it: if they ever did take informed consent seriously and informed their patients fully about the evidence and risks of their treatments as well as those of other therapeutic options, they would probably be out of business for ever. One the other hand, chiropractors should not be allowed to continue excluding themselves from the generally accepted ethical standards of modern health care.

A meta-analysis compared the effectiveness of spinal manipulation therapies (SMT), medical management, physical therapies, and exercise for acute and chronic low back pain. Studies were chosen based on inclusion in prior evidence syntheses. Effect sizes were converted to standardized mean effect sizes and probabilities of recovery. Nested model comparisons isolated non-specific from treatment effects. Aggregate data were tested for evidential support as compared to shams.

The results suggest that, of 84% acute pain variance, 81% was from non-specific factors and 3% from treatment. No treatment was better than sham. Most acute results were within 95% confidence bands of that predicted by natural history alone. For chronic pain, 66% out of 98% was non-specific, but treatments influenced 32% of outcomes. Chronic pain treatments also fitted within 95% confidence bands as predicted by natural history. The evidential support for treating chronic back pain as compared to sham groups was weak, but chronic pain appeared to respond to SMT, while whole systems of chiropractic management did not.

The authors of this intriguing paper conclude: Meta-analyses can extract comparative effectiveness information from existing literature. The relatively small portion of outcomes attributable to treatment explains why past research results fail to converge on stable estimates. The probability of treatment superiority between treatment arms was equivalent to that expected by random selection. Treatments serve to motivate, reassure, and calibrate patient expectations – features that might reduce medicalization and augment self-care. Exercise with authoritative support is an effective strategy for acute and chronic low back pain.

This essentially indicates that none of these treatments for low back pain are convincingly effective. In turn this means we might as well stop using them. Alternatively, we could opt for the therapy that carries the least risks and cost. As the authors point out, this treatment is exercise.

Do you think that chiropractic is effective for asthma? I don’t – in fact, I know it isn’t because, in 2009, I have published a systematic review of the available RCTs which showed quite clearly that the best evidence suggested chiropractic was ineffective for that condition.

But this is clearly not true, might some enthusiasts reply. What is more, they can even refer to a 2010 systematic review which indicates that chiropractic is effective; its conclusions speak a very clear language: …the eight retrieved studies indicated that chiropractic care showed improvements in subjective measures and, to a lesser degree objective measures… How on earth can this be?

I would not be surprised, if chiropractors claimed the discrepancy is due to the fact that Prof Ernst is biased. Others might point out that the more recent review includes more studies and thus ought to be more reliable. The newer review does, in fact, have about twice the number of studies than mine.

How come? Were plenty of new RCTs published during the 12 months that lay between the two publications? The answer is NO. But why then the discrepant conclusions?

The answer is much less puzzling than you might think. The ‘alchemists of alternative medicine’ regularly succeed in smuggling non-evidence into such reviews in order to beautify the overall picture and confirm their wishful thinking. The case of chiropractic for asthma does by no means stand alone, but it is a classic example of how we are being misled by charlatans.

Anyone who reads the full text of the two reviews mentioned above will find that they do, in fact, include exactly the same amount of RCTs. The reason why they arrive at different conclusions is simple: the enthusiasts’ review added NON-EVIDENCE to the existing RCTs. To be precise, the authors included one case series, one case study, one survey, two randomized controlled trials (RCTs), one randomized patient and observer blinded cross-over trial, one single blind cross study design, and one self-reported impairment questionnaire.

Now, there is nothing wrong with case reports, case series, or surveys – except THEY TELL US NOTHING ABOUT EFFECTIVENESS. I would bet my last shirt that the authors know all of that; yet they make fairly firm and positive conclusions about effectiveness. As the RCT-results collectively happen to be negative, they even pretend that case reports etc. outweigh the findings of RCTs.

And why do they do that? Because they are interested in the truth, or because they don’t mind using alchemy in order to mislead us? Your guess is as good as mine.

Systematic reviews are widely considered to be the most reliable type of evidence for judging the effectiveness of therapeutic interventions. Such reviews should be focused on a well-defined research question and identify, critically appraise and synthesize the totality of the high quality research evidence relevant to that question. Often it is possible to pool the data from individual studies and thus create a new numerical result of the existing evidence; in this case, we speak of a meta-analysis, a sub-category of systematic reviews.

One strength of systematic review is that they minimise selection and random biases by considering at the totality of the evidence of a pre-defined nature and quality. A crucial precondition, however, is that the quality of the primary studies is critically assessed. If this is done well, the researchers will usually be able to determine how robust any given result is, and whether high quality trials generate similar findings as those of lower quality. If there is a discrepancy between findings from rigorous and flimsy studies, it is obviously advisable to trust the former and discard the latter.

And this is where systematic reviews of alternative treatments can run into difficulties. For any given research question in this area we usually have a paucity of primary studies. Equally important is the fact that many of the available trials tend to be of low quality. Consequently, there often is a lack of high quality studies, and this makes it all the more important to include a robust critical evaluation of the primary data. Not doing so would render the overall result of the review less than reliable – in fact, such a paper would not qualify as a systematic review at all; it would be a pseudo-systematic review, i.e. a review which pretends to be systematic but, in fact, is not. Such papers are a menace in that they can seriously mislead us, particularly if we are not familiar with the essential requirements for a reliable review.

This is precisely where some promoters of bogus treatments seem to see their opportunity of making their unproven therapy look as though it was evidence-based. Pseudo-systematic reviews can be manipulated to yield a desired outcome. In my last post, I have shown that this can be done by including treatments which are effective so that an ineffective therapy appears effective (“chiropractic is so much more than just spinal manipulation”). An even simpler method is to exclude some of the studies that contradict one’s belief from the review. Obviously, the review would then not comprise the totality of the available evidence. But, unless the reader bothers to do a considerable amount of research, he/she would be highly unlikely to notice. All one needs to do is to smuggle the paper past the peer-review process – hardly a difficult task, given the plethora of alternative medicine journals that bend over backwards to publish any rubbish as long as it promotes alternative medicine.

Alternatively (or in addition) one can save oneself a lot of work and omit the process of critically evaluating the primary studies. This method is increasingly popular in alternative medicine. It is a fool-proof method of generating a false-positive overall result. As poor quality trials have a tendency to deliver false-positive results, it is obvious that a predominance of flimsy studies must create a false-positive result.

A particularly notorious example of a pseudo-systematic review that used this as well as most of the other tricks for misleading the reader is the famous ‘systematic’ review by Bronfort et al. It was commissioned by the UK GENERAL CHIROPRACTIC COUNCIL after the chiropractic profession got into trouble and was keen to defend those bogus treatments disclosed by Simon Singh. Bronfort and his colleagues thus swiftly published (of course, in a chiro-journal) an all-encompassing review attempting to show that, at least for some conditions, chiropractic was effective. Its lengthy conclusions seemed encouraging: Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation. Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic. 

Chiropractors across the world cite this paper as evidence that chiropractic has at least some evidence base. What they omit to tell us (perhaps because they do not appreciate it themselves) is the fact that Bronfort et al

  • failed to formulate a focussed research question,
  • invented his own categories of inconclusive findings,
  • included all sorts of studies which had nothing to do with chiropractic,
  • and did not to make an assessment of the quality of the included primary studies they included in their review.

If, for a certain condition, three trials were included, for instance, two of which were positive but of poor quality and one was negative but of good quality, the authors would conclude that, overall, there is sound evidence.

Bronfort himself is, of course, more than likely to know all that (he has learnt his trade with an excellent Dutch research team and published several high quality reviews) – but his readers mostly don’t. And for chiropractors, this ‘systematic’ review is now considered to be the most reliable evidence in their field.

Imagine a type of therapeutic intervention that has been shown to be useless. Let’s take surgery, for instance. Imagine that research had established with a high degree of certainty that surgical operations are ineffective. Imagine further that surgeons, once they can no longer hide this evidence, argue that good surgeons do much more than just operate: surgeons wash their hands which effectively reduces the risk of infections, they prescribe medications, they recommend rehabilitative and preventative treatments, etc. All of these measures are demonstratively effective in their own right, never mind the actual surgery. Therefore, surgeons could argue that the things surgeons do are demonstrably effective and helpful, even though surgery itself would be useless in this imagined scenario.

I am, of course, not for a minute claiming that surgery is rubbish, but I have used this rather extreme example to expose the flawed argument that is often used in alternative medicine for white-washing bogus treatments. The notion is that, because a particular alternative health care profession employs not just one but multiple forms of treatments, it should not be judged by the effectiveness of its signature-therapy, particularly if it happens to be ineffective.

This type of logic seems nowhere more prevalent than in the realm of chiropractic. Its founding father, D.D. Palmer, dreamt up the bizarre notion that all human disease is caused by ‘subluxations’ which require spinal manipulation for returning the ill person to good health. Consequently, most chiropractors see spinal manipulation as a panacea and use this type of treatment for almost 100% of their patients. In other words, spinal manipulation is as much the hallmark-therapy for chiropractic as surgery is for surgeons.

When someone points out that, for this or that condition, spinal manipulation is not of proven effectiveness or even of proven ineffectiveness, chiropractors have in recent years taken to answering as outlined above; they might say: WE DO ALL SORTS OF OTHER THINGS TOO, YOU KNOW. FOR INSTANCE, WE EMPLOY OTHER MANUAL TECHNIQUES, GIVE LIFE-STYLE ADVICE AND USE NO END OF PHYSIOTHERAPEUTIC INTERVENTIONS. YOU CANNOT SAY THAT THESE APPROACHES ARE BOGUS. THEREFORE CHIROPRACTIC IS FAR FROM USELESS.

To increase the chances of convincing us with this notion, they have, in recent months, produced dozens of ‘systematic reviews’ which allegedly prove their point. Here are some of the conclusions from these articles which usually get published in chiro-journals:

The use of manual techniques on children with respiratory diseases seems to be beneficial.

The majority of the included trials appeared to indicate that the parents of infants receiving manipulative therapies reported fewer hours crying per day than parents whose infants did not, based on contemporaneous crying diaries, and this difference was statistically significant.

A limited amount of research has been published that supports a role for manual therapy in improving postural stability and balance.

…a trial of chiropractic care for sufferers of autism is prudent and warranted.

This study found a level of B or fair evidence for manual manipulative therapy of the shoulder, shoulder girdle, and/or the FKC combined with multimodal or exercise therapy for rotator cuff injuries/disorders, disease, or dysfunction.

Chiropractic care is an alternative approach to the care of the child with colic.

There is a baseline of evidence that suggests chiropractic care improves cervical range of motion (cROM) and pain in the management of whiplash-associated disorders.

Results of the eight retrieved studies indicated that chiropractic care showed improvements [for asthma].

Personally, I find this kind of ‘logic’ irritatingly illogical. If we accept it as valid, the boundaries between sense and nonsense disappear, and our tools of differentiating between quackery and ethical health care become blunt.

The next step could then even be to claim that a homeopathic hospital must be a good thing because some of its clinicians occasionally also prescribe non-homeopathic treatments.

Preston Long’s book has featured on this blog before. It is truly an important contribution to the literature on chiropractic, and I recommend that anyone with an interest in the subject should read it. Harriet Hall wrote about it even if you think you’ve heard it all before, there are revelations here that will be new to you, that will elicit surprise, indignation, and laughter.

In a way, an even better ‘recommendation’ comes from someone who previously made numerous vile comments on my blog, Eugen Roth: In my opinion the close relationship that the author has with both Stephen Barrett and Prof Edzard Ernst makes this book just another part of the witch hunt against chiropractic which was initiated more than 50 years ago… In my opinion Prof Ernst and Dr Barrett have continued this witch hunt over many years and have now teamed up with the author to try and give credence to their misguided message. I have no ‘close relationship’ with Long, and his book is not a witch hunt; it is a factual and fascinating of chiropractic abuse, fraud and make-belief.

Chiropractors are in many ways not that different from other health care professionals. Most of them, like Preston Long, go into their profession with all the very best intentions; they study hard what is being taught at Chiropractic College; they pass their exams and set up a practice to earn a decent living. During their career, they subsequently treat thousands of patients, and many of them perceive some benefit. Those who don’t fail to return and are quickly forgotten. Over the years, chiropractors thus become convinced that their interventions are effective.

In several other ways, however, chiropractors differ from conventional health care professionals. The most fundamental differences, I think, relate to the facts that chiropractic is based on the erroneous dogma of its founding fathers, and that chiropractors fail to abide by the rules of evidence-based medicine and practice. Preston Long writes eloquently about many other rules which some chiropractors fail to abide to in addition.

D.D. Palmer, the ‘inventor’ of chiropractic, believed that all human illness was the result of ‘subluxations’ of the spine which impeded the flow of the ‘Innate’ and required correction through spinal adjustments. To his followers, this new approach to healing was the only correct one – one that could cure all health problems. When these assumptions were first formulated, more than a century ago, they might not even have appeared entirely ridiculous; today, in the face of an immense amount of new knowledge, they can easily be disclosed as pure fantasy and chiropractors who believe in Palmer’s gospel have become the laughing stock of all health care professionals.

Some chiropractors are therefore struggling to free themselves from the burden of Palmer’s nonsensical notions. But this struggle rarely is entirely successful. After all, chiropractors have been to Chiropractic College where they memorised so many falsehoods, were kept from numerous important truths, and failed to acquire the essential skills of being (self-) critical. As a result, most find it virtually impossible to completely recover from the ‘brain-wash’ they were submitted to at the beginning of their career. And even if some courageous innovators, one day, managed to expunge all the falsehoods, myths and bogus claims from their profession, the obvious question would still be, how would such a ‘chiropractic minus woo’ differ from physiotherapy?

Most chiropractors have very little inkling what evidence-based practice amounts to; the good intentions that once motivated them have long given way to the need to make money. They are unable to critically assess their own activities, and all the bogus claims they have been exposed to are thus endlessly and profitably perpetuated. The principles of medical ethics have remained alien to most of them. In fact, ‘evidence-based chiropractic’ is an oxymoron: either you abide by evidence – in which case you cannot possibly conceive the idea of adjusting spinal ‘subluxations’ – or you believe in the myth of ‘subluxations’ in which case your practice is not evidence-based. Long is right, I think, when he states: the most efficient way to protect against chiropractic mistreatment is to avoid chiropractors altogether.

Whenever someone dares to criticise their bizarre interventions, chiropractors react with anger, personal attacks, defamation or even libel suits. One argument that is voiced with unfailing regularity in such a context is the claim that the critic lacks the knowledge, insight and experience to be credible. External criticism is thus usually completely ignored.

Preston Long has been a chiropractor himself, and therefore his authority, inside knowledge and expertise cannot be undermined in this fashion. He knows what he is writing about and has been an eye-witness to most of the abuses he reports in his book. His comments are not criticism from the outside; they are thoughtful insights, hand-on experiences and first-hand accounts of fraud and abuse which originate from the very heart of chiropractic. It is this fact that makes this book unique.

Preston Long’s book provides a most valuable perspective on the education, training, thinking, misunderstandings, wrong-doings and unethical behaviours of chiropractors. He also gives valuable instructions on how we can protect ourselves against chiropractic abuse. It would be nice to think that Long’s outstanding and in many ways constructive criticism might contribute to a much-needed and long over-due reformation of chiropractic; but I would not hold my breath.

The very first article on chiropractic listed in ‘Medline’ was published 100 years ago in the ‘California State Journal of Medicine’ without the author’s name. It is a beauty! Here I take the liberty of re-publishing it in full.

Some people are really so terribly modest that it is a mystery how they can live, or even be willing to live, in a world so filled with pushing braggarts and rampant commercialism. For example, note the list of things that E. R. Blanchard D.C., (graduate chiropractor), intimates that he can cure:

“Adhesions, anemia, asthma, appendicitis, blood poison, bronchitis, backache, biliousness, catarrh, constipation, chills and fever, diabetes, dropsy, dizziness, drug and alcohol habits, diarrhoea, deafness, eczema, eye diseases, female diseases, gallstones, gravel, goitre, hay fever, indigestion, lumbago, locomotor ataxia, malaria, nervousness, neuralgia, paralysis, piles, pneumonia, rickets, ruptures, rheumatism, St. Vitus’ dance, suppressed or painful menstruation, scrofula, tumors, worms, bed wetting and other child’s diseases, leucorrhoea, or whites, stricture, emissions, impotence and many other diseases.”

This is almost as long a list as that compiled by the wealthy and admired Law brothers in connection with what they say they can cure with the wonderful Viavi, that prize of all fakes!

One hundred years later, it seems to me, not a lot has changed:

A review of 200 chiropractor websites and 9 chiropractic associations’ claims in Australia, Canada, New Zealand, the United Kingdom, and the United States was conducted between. The outcome measure was claims (either direct or indirect) regarding eight reviewed conditions, made in the context of chiropractic treatment. The results demonstrated that 190 (95%) chiropractor websites made unsubstantiated claims.

If we ask how effective spinal manipulation is as a treatment of back pain, we get all sorts of answers. Therapists who earn their money with it – mostly chiropractors, osteopaths and physiotherapists – are obviously convinced that it is effective. But if we consult more objective sources, the picture changes dramatically. The current Cochrane review, for instance, arrives at this conclusion: SMT is no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention. SMT also appears to be no better than other recommended therapies.

Such reviews tend to pool all studies together regardless of the nature of the practitioner. But perhaps one type of clinician is better than the next? Certainly many chiropractors are on record claiming that they are the best at spinal manipulations. Yet it is conceivable that physiotherapists who do manipulations without being guided by the myth of ‘adjusting subluxations’ have an advantage over chiropractors. Three very recent systematic reviews might go some way to answer these questions.

The purpose of the first systematic review was to examine the effectiveness of spinal manipulations performed by physiotherapists for the treatment of patients with low back pain. The authors found 6 RCTs that met their inclusion criteria. The most commonly used outcomes were pain rating scales and disability indexes. Notable results included varying degrees of effect sizes favouring spinal manipulations and minimal adverse events resulting from this intervention. Additionally, the manipulation group in one study reported significantly less medication use, health care utilization, and lost work time. The authors concluded that there is evidence to support the use of spinal manipulation by physical therapists in clinical practice. Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain.

The second systematic Review was of osteopathic intervention for chronic, non-specific low back pain (CNSLBP). Only two trials met the authors’ inclusion criteria. They had a lack of methodological and clinical homogeneity, precluding a meta-analysis. The trials used different comparators with regards to the primary outcomes, the number of treatments, the duration of treatment and the duration of follow-up. The authors drew the following conclusions: There are only two studies assessing the effect of the manual therapy intervention applied by osteopathic clinicians in adults with CNSLBP. One trial concluded that the osteopathic intervention was similar in effect to a sham intervention, and the other suggests similarity of effect between osteopathic intervention, exercise and physiotherapy. Further clinical trials into this subject are required that have consistent and rigorous methods. These trials need to include an appropriate control and utilise an intervention that reflects actual practice.

The third systematic review sought to determine the benefits of chiropractic treatment and care for back pain on well-being, and aimed to explore to what extent chiropractic treatment and care improve quality of life. The authors identified 6 studies (4 RCTs and two observational studies) of varying quality. There was a high degree of inconsistency and lack of standardisation in measurement instruments and outcome measures. Three studies reported reduced use of other/extra treatments as a positive outcome; two studies reported a positive effect of chiropractic intervention on pain, and two studies reported a positive effect on disability. The authors concluded that it is difficult to defend any conclusion about the impact of chiropractic intervention on the quality of life, lifestyle, health and economic impact on chiropractic patients presenting with back pain.

Yes, yes, yes, I know: the three reviews are not exactly comparable; so we cannot draw firm conclusions from comparing them. Five points seem to emerge nevertheless:

  1. The evidence for spinal manipulation as a treatment for back pain is generally not brilliant, regardless of the type of therapist.
  2. There seem to be considerable differences according to the nature of the therapist.
  3. Physiotherapists seem to have relatively sound evidence to justify their manipulations.
  4. Chiropractors and osteopaths are not backed by evidence which is as reliable as they so often try to make us believe.
  5. Considering that the vast majority of serious complications after spinal manipulation has occurred with chiropractors, it would seem that chiropractors are the profession with the worst track record regarding manipulation for back pain.

Some experts concede that chiropractic spinal manipulation is effective for chronic low back pain (cLBP). But what is the right dose? There have been no full-scale trials of the optimal number of treatments with spinal manipulation. This study was aimed at filling this gap by trying to identify a dose-response relationship between the number of visits to a chiropractor for spinal manipulation and cLBP outcomes. A further aim was to determine the efficacy of manipulation by comparison with a light massage control.

The primary cLBP outcomes were the 100-point pain intensity scale and functional disability scales evaluated at the 12- and 24-week primary end points. Secondary outcomes included days with pain and functional disability, pain unpleasantness, global perceived improvement, medication use, and general health status.

One hundred patients with cLBP were randomized to each of 4 dose levels of care: 0, 6, 12, or 18 sessions of spinal manipulation from a chiropractor. Participants were treated three times per week for 6 weeks. At sessions when manipulation was not assigned, the patients received a focused light massage control. Covariate-adjusted linear dose effects and comparisons with the no-manipulation control group were evaluated at 6, 12, 18, 24, 39, and 52 weeks.

For the primary outcomes, mean pain and disability improvement in the manipulation groups were 20 points by 12 weeks, an effect that was sustainable to 52 weeks. Linear dose-response effects were small, reaching about two points per 6 manipulation sessions at 12 and 52 weeks for both variables. At 12 weeks, the greatest differences compared to the no-manipulation controls were found for 12 sessions (8.6 pain and 7.6 disability points); at 24 weeks, differences were negligible; and at 52 weeks, the greatest group differences were seen for 18 visits (5.9 pain and 8.8 disability points).

The authors concluded that the number of spinal manipulation visits had modest effects on cLBP outcomes above those of 18 hands-on visits to a chiropractor. Overall, 12 visits yielded the most favorable results but was not well distinguished from other dose levels.

This study is interesting because it confirms that the effects of chiropractic spinal manipulation as a treatment for cLBP are tiny and probably not clinically relevant. And even these tiny effects might not be due to the treatment per se but could be caused by residual confounding and bias.

As for the optimal dose, the authors suggest that, on average, 18 sessions might be the best. But again, we have to be clear that the dose-response effects were small and of doubtful clinical relevance. Since the therapeutic effects are tiny, it is obviously difficult to establish a dose-response relationship.

In view of the cost of chiropractic spinal manipulation and the uncertainty about its safety, I would probably not rate this approach as the treatment of choice but would consider the current Cochrane review which concludes that “high quality evidence suggests that there is no clinically relevant difference between spinal manipulation and other interventions for reducing pain and improving function in patients with chronic low-back pain” Personally, I think it is more prudent to recommend exercise, back school, massage or perhaps even yoga to cLBP-sufferers.

Many reader of this blog will remember the libel case of the British Chiropractic Association (BCA) against Simon Singh. Simon had disclosed in a Guardian comment that the BCA was happily promoting bogus chiropractic treatments for 6 paediatric conditions, including infant colic. The BCA not only lost the case but the affair almost destroyed this strange organisation and resulted in an enormous reputational damage of chiropractors worldwide. In an article entitled AFTER THE STORM, the then-president of the BCA later described the defeat in his own words: “in 2009, events in the UK took a turn which was to consume the British Chiropractic Association (BCA) for two years and force the wider profession to confront key issues that for decades had kept it distanced from its medical counterparts and attracting ridicule from its critics…the BCA began one of the darkest periods in its history; one that was ultimately to cost it financially, reputationally and politically…The GCC itself was in an unprecedented situation. Faced with a 1500% rise in complaints, Investigating Committees were assembled to determine whether there was a case to answer…The events of the past two years have exposed a blind adherence to outdated principles amongst a small but significant minority of the profession. Mindful of the adage that it’s the squeaky wheel that gets the grease, the vocalism of this group has ensured that chiropractic is characterised by its critics as unscientific, unsafe and slightly wacky. Claims that the vertebral subluxation complex is the cause of illness and disease have persisted despite the three UK educational establishments advising the GCC that no evidence of acceptable quality exists to support such claims.”

Only a few years AFTER THE STORM, this story seems to have changed beyond recognition. Harald Walach, who is known to readers of this blog because I reported that he was elected ‘pseudo-scientist of the year’ in 2012, recently published a comment on the proceedings of the European Congress of Integrated Medicine where we find the following intriguing version of the libel case:

Mein Freund und Kollege George Lewith aus Southampton hatte einen Hauptvortrag über seine Überblicksarbeit über chiropraktische Interventionen für kleinkindliche Koliken vorgelegt. Sie ist ausgelöst worden durch die Behauptung, die Singh und Ernst vor einigen Jahren erhoben hatten, dass Chiropraktik gefährlich ist, dass es keine Daten dafür gäbe, dass sie wirksam sei und dass sie gefährliche Nebenwirkungen habe, speziell wenn sie bei Kindern angewendet würde. Die Chiropraktiker hatten den Wissenschaftsjournalisten Singh damals wegen Verleumdung verklagt und recht erhalten. George Lewith hatte dem Gericht die Expertise geliefert und nun seine Analyse auf Kinder ausgedehnt.

Kurz gefasst: Die Intervention wirkt sogar ziemlich stark, etwa eine Standardabweichung war der Effekt groß. Die Kinder schreien kürzer und weniger. Und die Durchforstung der Literatur nach gefährlichen Nebenwirkungen hatte keinen, wortwörtlich: nicht einen, Fall zu Tage gefördert, der von Nebenwirkungen, geschweige denn gefährlichen, berichtet hätte. Die Aufregung war seinerzeit dadurch entstanden, dass eine unqualifizierte Person einer zart gebauten Frau über den Rücken gelaufen ist und ihr dabei das Genick gebrochen hat. Die Presse hatte das ganze dann zu „tödlicher Nebenwirkung chiropraktischer Intervention“ aufgebauscht.

Oh, I almost forgot, you don’t read German? Here is my translation of this revealing text:

“My friend and colleague Geoorge Lewith from Southampton gave a keynote lecture on his review of chiropractic interventions for infant colic. This was prompted by the claim, made by Singh and Ernst a few years ago, that chiropractic was dangerous, that no data existed showing its effectiveness, and that it had dangerous side-effects, particularly for children. The chiropractors had sued the science journalist Singh for libel and won the case. George Lewith had provided the expert report for the court and has now extended his analysis on children.

To put it briefly: the intervention is even very effective; the effect-size is about one standard deviation. The children cry less long and more rarely. And the search of the literature for dangerous side-effects resulted in no – literally: not one – case of side-effects, not to mention dangerous ones. The fuzz had started back then because an unqualified person had walked over the back of a thin woman and had thus broken her neck. The press had subsequently hyped the whole thing to a “deadly side-effect of a chiropractic intervention”. (I am sorry for the clumsy language but the original is even worse.)

Now, isn’t that remarkable? Not only has the truth about the libel case been turned upside down, but also the evidence on chiropractic as a treatment for infant colic seems mysteriously improved; other reviews which might just be a bit more independent and objective come to the following conclusions:

The literature concerning this topic is surprisingly scarce, of poor quality and lack of convincing conclusions. With the present day data on this topic, it is impossible to say whether this kind of treatment has a significant effect.

The totality of this evidence fails to demonstrate the effectiveness of this treatment. It is concluded that the above claim is not based on convincing data from rigorous clinical trials.

And what should we make of all this? I don’t know about you, but I conclude that, for some apologists of alternative medicine, the truth is a rather flexible commodity.

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