At a recent conference in Montréal (October 2016), the WFC (World Federation of Chiropractic) and the ACC (Association of Chiropractic Colleges) reached a consensus on education. Consequently, recommendations were produced that offer 12 key ‘take away messages’. I take the liberty of reproducing these statements entitled ‘Training Tomorrow’s Spine Care Experts’ (the square brackets were inserted by me and refer to brief comments I made below).
START OF QUOTE
1. Chiropractic educational institutions have a responsibility to equip students with the skills and attributes necessary to become future spinal health care experts. This includes a commitment to astute diagnostic ability, a comprehensive knowledge of spine-related disorders , appreciation for the contributions of other health professionals and a commitment to collaborative, patient-centered and evidence-informed care .
2. Technological advances  provide an opportunity for the chiropractic profession to enhance, evolve and standardize core education and practice. This is relevant to the teaching of chiropractic skills, sharing of learning resources and assessment of performance. Emerging technologies that support the development of clinically-competent practitioners should be embedded within chiropractic programs.
3. The teaching and learning of specialized manual assessment and treatment skills should remain a key distinguishing element of chiropractic curricula.
4. Surveys of the public have a demonstrated a desire for consistency in the provision of chiropractic services. Such consistency need not compromise the identities of individual institutions but will cultivate public trust and cultural authority .
5. Globally consistent educational and practice standards will facilitate international portability  and promote greater health equity in the delivery of spine care.
6. Chiropractic programs should espouse innovation and leadership in the context of ethical , sustainable business  practices.
7. Chiropractic educational curricula should reflect current evidence  and high quality guidelines , and be subjected to regular review to ensure that students are prepared to work in collaborative health care environments.
8. The training of tomorrow’ s spine care experts should incorporate current best practices in education.
9. Interdisciplinary collaboration and strategic partnerships present opportunities to position chiropractors as leaders  and integral team players in global spine care.
10. Chiropractic educational institutions should champion the integration of evidence informed clinical practice , including clinical practice guidelines, in order to optimize patient outcomes. This will in turn foster principles of lifelong learning and willingness to adapt practice methods in the light of emerging evidence .
11. Students, faculty, staff and administrators must all contribute to a learning environment that fosters cultural diversity, critical thinking , academic responsibility and scholarly activity.
12. Resources should be dedicated to embed and promote educational research activity in all chiropractic institutions.
END OF QUOTE
And here are my brief comments: Some chiropractors believe that all or most human conditions are ‘spine-related disorders’. We would need a clear statement here whether the WFC/ACC do support or reject this notion and what conditions we are actually talking about.  ‘Evidence-informed’??? I have come across this term before; it is used more and more by quacks of all types. It is clearly not synonymous with ‘evidence-based’, but aims at providing a veneer of respectability by creation an association with EBM. In concrete terms, asthma, for instance, might, in the eyes of some chiropractors, be an evidence-informed indication for chiropractic. In other words, ‘evidence-informed’ is merely a card blanch for promoting all sorts of nonsense.  It would be good to know which technical advances they are thinking of.  Public trust is best cultivated by demonstrating that chiropractic is doing more good than harm; by itself, this point sounds a bit like PR for maximising income. Sorry, I am not sure what they mean by ‘cultural authority’ – chiropractic as a cult?  ‘International portability’ – nice term, but what does it mean?  I get the impression that many chiropractors do not know what is meant by the term ‘ethics’.  But they certainly know much about business!  That is, I think, the most relevant statement in the entire text – see below.  Like those by NICE which no longer recommend chiropractic for back pain? No? They are not ‘high quality’? I see, only those that recommend chiropractic fulfil this criterion!  Chiropractors as leaders? Really? With their (largely ineffective) manipulations as the main contribution to the field? You have to be a chiropractor to find this realistic, I guess.  Again ‘evidence-informed’ instead of ‘evidence-based’ – who are they trying to kid?  The evidence that has been emerging since many years is that chiropractic manipulations fail to generate more good than harm.  In the past, I got the impression that critical thinking and chiropractic are a bit like fire and water.
MY CONCLUSION FROM ALL THIS
What we have here is, in my view, little more than a mixture between politically correct drivel and wishful thinking. If chiropractors truly want chiropractic educational curricula to “reflect current evidence”, they need to teach the following main tenets:
- Chiropractic manipulations have not been shown to be effective for any of the conditions they are currently used for.
- Other forms of treatment are invariably preferable.
- Subluxation, as defined by chiropractors, is a myth.
- Spine-related disorders, as taught in many chiropractic colleges, are a myth.
- ‘Evidence-informed’ is a term that has no meaning; the proper word is ‘evidence-based’ – and evidence-based chiropractic is a contradiction in terms.
Finally, chiropractors need to be aware of the fact that any curriculum for future clinicians must include the core elements of critical assessment and medical ethics. The two combined would automatically discontinue the worst excesses of chiropractic abuse, such as the promotion of bogus claims or the financial exploitation of the public.
But, of course, none of this is ever going to happen! Why? Because it would mean teaching students that they need to find a different profession. And this is why I feel that statements like the above are politically correct drivel which can serve only one purpose: to distract everyone from the fundamental problems in that profession.
Yes, to a large extend, quacks make a living by advertising lies. A paper just published confirms our worst fears.
This survey was aimed at identifying the frequency and qualitative characteristics of marketing claims made by Canadian chiropractors, naturopaths, homeopaths and acupuncturists relating to the diagnosis and treatment of allergy and asthma.
A total of 392 chiropractic, naturopathic, homeopathic and acupuncture clinic websites were located in 10 of the largest metropolitan areas in Canada. The main outcome measures were: mention of allergy, sensitivity or asthma, claim of ability to diagnose allergy, sensitivity or asthma, claim of ability to treat allergy, sensitivity or asthma, and claim of allergy, sensitivity or asthma treatment efficacy. Tests and treatments promoted were noted as qualitative examples.
The results show that naturopath clinic websites had the highest rates of advertising at least one of diagnosis, treatment or efficacy for allergy or sensitivity (85%) and asthma (64%), followed by acupuncturists (68% and 53%, respectively), homeopaths (60% and 54%) and chiropractors (33% and 38%). Search results from Vancouver were most likely to advertise at least one of diagnosis, treatment or efficacy for allergy or sensitivity (72.5%) and asthma (62.5%), and results from London, Ontario were least likely (50% and 40%, respectively). Of the interventions advertised, few are scientifically supported; the majority lack evidence of efficacy, and some are potentially harmful.
The authors concluded that the majority of alternative healthcare clinics studied advertised interventions for allergy and asthma. Many offerings are unproven. A policy response may be warranted in order to safeguard the public interest.
In the discussion section, the authors state: “These claims raise ethical issues, because evidence in support of many of the tests and treatments identified on the websites studied is lacking. For example, food-specific IgG testing was commonly advertised, despite the fact that the Canadian Society of Allergy and Clinical Immunology has recommended not to use this test due to the absence of a body of research supporting it. Live blood analysis, vega/electrodiagnostic testing, intravenous vitamin C, probiotics, homeopathic allergy remedies and several other tests and treatments offered all lack substantial scientific evidence of efficacy. Some of the proposed treatments are so absurd that they lack even the most basic scientific plausibility, such as ionic foot bath detoxification…
Perhaps most concerning is the fact that several proposed treatments for allergy, sensitivity or asthma are potentially harmful. These include intravenous hydrogen peroxide, spinal manipulation and possibly others. Furthermore, a negative effect of the use of invalid and inaccurate allergy testing is the likelihood that such testing will lead to alterations and exclusions in diets, which can subsequently result in malnutrition and other physiological problems…”
This survey originates from Canada, and one might argue that elsewhere the situation is not quite as bad. However, I would doubt it; on the contrary, I would not be surprised to learn that, in some other countries, it is even worse.
Several national regulators have, at long last, become aware of the dangers of advertising of outright quackery. Consequently, some measures are now beginning to be taken against it. I would nevertheless argue that these actions are far too slow and by no means sufficiently effective.
We easily forget that asthma, for instance, is a potentially life-threatening disease. Advertising of bogus claims is therefore much more than a forgivable exaggeration aimed at maximising the income of alternative practitioners – it is a serious threat to public health.
We must insist that regulators protect us from such quackery and prevent the serious harm it can do.
The boom of alternative medicine in the US – and consequently in the rest of the developed world – is intimately connected with a NHI centre now called NCCIH (National Center for Complementary and Integrative Health). It was founded in the early 1990s because some politicians were bent on promoting quackery. Initially the institution had modest funding but, after more political interference, it had ample cash to pursue all sorts of activities, including sponsoring research into alternative therapies at US universities. A most interesting video summarising the history of the NCCIH can be seen here.
No other institution in the world had more funds for research into alternative medicine than the NCCIH, and it soon became the envy of alt med researchers globally. I have been invited by the NCCHI on several occasions and invariably was impressed by their apparent affluence. While we Europeans usually had to do our research on a shoe-string, our American colleagues seemed to be ‘rolling in it’.
I was often far less impressed with the research they sponsored. Not only it was invariably eye-wateringly expensive, but also its quality seemed often dismal. Sometimes, I even got the impression that research was used as a means of mainstreaming quackery for the unsuspecting American – and consequently world-wide – public.
An example of this mainstreaming is an article in JAMA published yesterday. Here is a short but telling excerpt:
Researchers led by Richard L. Nahin, PhD, MPH, lead epidemiologist at the NIH’s National Center for Complementary and Integrative Health (NCCIH), examined efficacy and safety evidence in 105 randomized controlled trials (RCTs) conducted between January 1966 and March 2016. The review—geared toward primary care physicians as part of the journal’s Symposium on Pain Medicine—focused on popular complementary approaches to common pain conditions.
Unlike a typical systematic review that assigns quality values to the studies, the investigators conducted a narrative review, in which they simply looked at the number of positive and negative trials. “If there were more positives than negatives then we generally felt the approach had some value,” Nahin explained. “If there were more negatives, we generally felt the approach had less value.” Trials that were conducted outside of the United States were excluded from the review.
Based on a “preponderance” of positive vs negative trials, complementary approaches that may offer pain relief include acupuncture and yoga for back pain; acupuncture and tai chi for osteoarthritis of the knee; massage therapy for neck pain; and relaxation techniques for severe headaches and migraine. Several other techniques had weaker evidence, according to the qualitative assessments, for specific pain conditions (see “Selected Complementary Health Approaches for Pain”). The treatments were generally safe, with no serious adverse events reported.
To me, this looks that NCCIH has now managed to persuade even the editors of JAMA to white-wash their dodgy science. The review referred to here is a paper we discussed some time ago on this blog. I then stated about it the following:
Reading the article carefully, it is impossible not to get troubled. Here are a few points that concern me most:
- the safety of a therapy cannot be evaluated on the basis of data from RCTs (particularly as it has been shown repeatedly that trials of alternative therapies often fail to report adverse effects); much larger samples are needed for that; any statements about safety in the aims of the paper are therefore misplaced;
- the authors talk about efficacy but seem to mean effectiveness;
- the authors only included RCTs from the US which must result in a skewed and incomplete picture;
- the article is from the National Center for Complementary and Integrative Health which is part of the NIH but which has been criticised repeatedly for being biased in favour of alternative medicine;
- not all of the authors seem to be NIH staff, and I cannot find a declaration of conflicts of interest;
- the discussion of the paper totally lacks any critical thinking;
- there is no assessment of the quality of the trials included in this review.
My last point is by far the most important. A summary of this nature that fails to take into account the numerous limitations of the primary data is, I think, as good as worthless. As I know most of the RCTs included in the analyses, I predict that the overall picture generated by this review would have changed substantially, if the risks of bias in the primary studies had been accounted for.
I find it puzzling that the ‘lead epidemiologist at the NIH’s National Center for Complementary and Integrative Health’ would publish such dubious research. Why does he do it? If you have watched the video mentioned above, you are inclined to think that it might be because of political interference.
However, I suggest another, in a way much more damming reason or contributing factor: the NCCIH has so long indulged in such poor science that even its top people have forgotten what good science looks like. I know this is a bold hypothesis; so, let me try to support it with some data.
Several years ago, my team together with several other researches have looked at the NCCIH-sponsored research systematically according to 4 different subject areas. Here are the conclusions of our articles reporting the findings:
Seven RCTs had a low risk of bias. Numerous methodological shortcomings were identified. Many NCCAM-funded RCTs of acupuncture have important limitations. These findings might improve future studies of acupuncture and could be considered in the ongoing debate regarding NCCAM-funding. [Focus on Alternative and Complementary Therapies Volume 17(1) March 2012 15–21]
This independent assessment revealed a plethora of serious concerns related to NCCAM studies of herbal medicine. [Perfusion 2011; 24: 89-102]
In conclusion, the NCCAM-funded RCTs of energy medicine are prime examples of misguided investments into research. In our opinion, NCCAM should not be funding poor-quality studies of implausible practices. The impact of any future studies of energy medicine would be negligible or even detrimental. [Focus on Alternative and Complementary Therapies Volume 16(2) June 2011 106–109 ]
In conclusion, our review demonstrates that several RCTs of chiropractic have been funded by the NCCAM. It raises numerous concerns in relation to these studies; in particular, it suggests that many of these studies are seriously flawed. [https://www.ncbi.nlm.nih.gov/pubmed/21207089]
I think I can rest my case and urge you to watch the video mentioned above.
Alternative medicine suffers from what might be called ‘survey overload’: there are far too much such investigations and most of them are of deplorably poor quality producing nothing of value except some promotion for alternative medicine. Yet, every now and then, one finds a paper that is worth reading, and I am happy to say that this survey (even though it has several methodological shortcomings) belongs in this category.
This cross-sectional assessment of the views of general practitioners towards chiropractors and osteopaths was funded by the Department of Chiropractic at Macquarie University. It was designed as a quantitative descriptive study using an anonymous online survey that included closed and open-ended questions with opportunities provided for free text. The target population was Australian general practitioners. Inclusion criteria included current medical registration, membership of the Royal Australian College of General Practitioners and currently practicing as a general practitioner in Australia. The data being reported here were collected between May and December, 2014.
There were 630 respondents to the online survey during this period representing a response rate of 2.6 %. Results were not uniform for the two professions. More general practitioners believed chiropractic education was not evidence-based compared to osteopathic education (70 % and 50 % respectively), while the scope of practice was viewed as similar for both professions. A majority of general practitioners had never referred a patient to either profession (chiropractic: 60 %; osteopathy: 66 %) and indicated that they would not want to co-manage patients with either profession. Approximately two-thirds of general practitioners were not interested in learning more about their education (chiropractors: 68 %; osteopaths: 63 %).
The authors concluded that this study provides an indication of the current views of Australian general practitioners towards chiropractors and osteopaths. The findings suggest that attitudes may have become less favourable with a growing intolerance towards both professions. If confirmed, this has the potential to impact health service provision. The results from this cross-sectional study suggest that obtaining representative general practitioner views using online surveys is difficult and another approach is needed to supplement or replace the current recruitment strategy.
The authors do not speculate on the reasons why the attitudes of general practitioners towards chiropractic and osteopathy might have become more critical. Therefore I decided to offer a few possibilities here. The more negative views could be due to:
- better education of general practitioners,
- tightening of healthcare budgets,
- recent ‘bad press’ and loss of reputation (for instance, the BCA’s libel action against Simon Singh),
- the work of sceptics in informing the public about the numerous bogus claims made by osteopaths and chiropractors,
- the plethora of overtly bogus claims which nevertheless continue to be made by these practitioners on a daily basis,
- a more general realisation that these therapies can cause very serious harm,
- a mixture of the above factors.
Whatever the reasons are, the finding that there now seems to be a growing scepticism (in Australia, but hopefully elsewhere as well) about the value of chiropractic and osteopathy is something that cheers me up no end.
The risks of consulting a chiropractor have regularly been the subject of this blog (see for instance here, here and here). My critics believe that I am alarmist and have a bee in my bonnet. I think they are mistaken and believe it is important to warn the public of the serious complications that are being reported with depressing regularity, particularly in connection with neck manipulations.
It has been reported that the American model Katie May died earlier this year “as the result of visiting a chiropractor for an adjustment, which ultimately left her with a fatal tear to an artery in her neck” This is the conclusion drawn by the L.A. County Coroner.
According to Wikipedia, Katie tweeted on January 29, 2016, that she had “pinched a nerve in [her] neck on a photoshoot” and “got adjusted” at a chiropractor. She tweeted on January 31, 2016 that she was “going back to the chiropractor tomorrow.” On the evening of February 1, 2016, May “had begun feeling numbness in a hand and dizzy” and “called her parents to tell them she thought she was going to pass out.” At her family’s urging, May went to Cedars Sinai Hospital; she was found to be suffering a “massive stroke.” According to her father, she “was not conscious when we got to finally see her the next day. We never got to talk to her again.” Life support was withdrawn on February 4, 2016.
Katie’s death certificate states that she died when a blunt force injury tore her left vertebral artery, and cut off blood flow to her brain. It also says the injury was sustained during a “neck manipulation by chiropractor.” Her death is listed as accidental.
Katie’s family is said to be aware of the coroner’s findings. They would not comment on whether they or her estate would pursue legal action.
The coroner’s verdict ends the uncertainty about Katie’s tragic death which was well and wisely expressed elsewhere:
“…The bottom line is that we don’t know for sure. We can’t know for sure. If you leave out the chiropractic manipulations of her neck, her clinical history—at least as far as I can ascertain it from existing news reports—is classic for a dissection due to neck trauma. She was, after all, a young person who suffered a seemingly relatively minor neck injury that, unbeknownst to her, could have caused a carotid artery dissection, leading to a stroke four or five days later… Thus, it seems to be jumping to conclusions for May’s friend Christina Passanisi to say that May “really didn’t need to have her neck adjusted, and it killed her.” … Her two chiropractic manipulations might well have either worsened an existing intimal tear or caused a new one that led to her demise. Or they might have had nothing to do with her stroke, her fate having been sealed days before when she fell during that photoshoot. There is just no way of knowing for sure. It is certainly not wrong to suspect that chiropractic neck manipulation might have contributed to Katie May’s demise, but it is incorrect to state with any degree of certainty that her manipulation did kill her.”
My conclusions are as before and I think they need to be put as bluntly as possible: avoid chiropractors – the possible risks outweigh the documented benefits – and if you simply cannot resist consulting one: DON’T LET HIM/HER TOUCH YOUR NECK!
This is your occasion to meet some of the most influential and progressive people in health care today! An occasion too good to be missed! The future of medicine is integrated – we all know that, of course. Here you can learn some of the key messages and techniques from the horses’ mouths. Book now before the last places have gone; at £300, this is a bargain!!!
The COLLEGE OF MEDICINE announced the event with the following words:
This two-day course led by Professor David Peters and Dr Michael Dixon will provide an introduction to integrated health and care. It is open to all clinicians but should be particularly helpful for GPs and nurses, who are interested in looking beyond the conventional biomedical box.
The course will include sessions on lifestyle approaches, social prescribing, mind/body therapies and cover most mainstream complementary therapies.
The aim of the course will be to demonstrate our healing potential beyond prescribing and referral, to provide information that will be useful in discussing non-conventional treatment options with patients and to teach some basic skills that can be used in clinical practice. The latter will include breathing techniques, basic manipulation and acupuncture, mind/body therapies including self-hypnosis and a limited range of herbal remedies. There will also be an opportunity to discuss how those attending might begin to integrate their everyday clinical practice.
The course will qualify for Continuing Professional Development hours and can provide a first stage towards a Fellowship of the College.
Both Dixon and Peters have been featured on this blog before. I have also commented regularly on the wonders of integrated (or was it integrative?) medicine. And I have even blogged about the College of Medicine and what it stands for. So readers of this blog know about the players as well as the issues for this event. Now it surely must be time to learn more from those who are much better placed than I to teach about bogus claims, phoney theories and unethical practices.
What are you waiting for? Book now – they would love to have a few rationalists in the audience, I am sure.
Chiropractors may not be good at treating diseases or symptoms, but they are certainly good at promoting their trade. As this trade hardly does more good than harm, one could argue that chiropractors are promoting bogus and potentially harmful treatments to fill their own pockets.
Does that sound too harsh? If you think so, please read what Canadian researchers have just published:
This study aimed to investigate the presence of critiques and debates surrounding efficacy and risk of Spinal Manipulative Therapy (SMT) on the social media platform Twitter. Specifically, it examined whether there is presence of debate and whether critical information is being widely disseminated.
An initial corpus of 31,339 tweets was compiled through Twitter’s Search Application Programming Interface using the query terms “chiropractic,” “chiropractor,” and “spinal manipulation therapy.” Tweets were collected for the month of December 2015. Post removal of tweets made by bots and spam, the corpus totalled 20,695 tweets, of which a sample (n=1267) was analysed for sceptical or critical tweets.
The results showed that there were 34 tweets explicitly containing scepticism or critique of SMT, representing 2.68% of the sample (n=1267). As such, there is a presence of 2.68% of tweets in the total corpus, 95% CI 0-6.58% displaying explicitly sceptical or critical perspectives of SMT. In addition, there are numerous tweets highlighting the health benefits of SMT for health issues such as attention deficit hyperactivity disorder (ADHD), immune system, and blood pressure that receive scant critical attention. The presence of tweets in the corpus highlighting the risks of “stroke” and “vertebral artery dissection” is also minute (0.1%).
The authors drew the following conclusions: In the abundance of tweets substantiating and promoting chiropractic and SMT as sound health practices and valuable business endeavors, the debates surrounding the efficacy and risks of SMT on Twitter are almost completely absent. Although there are some critical voices of SMT proving to be influential, issues persist regarding how widely this information is being disseminated.
I have no doubt that this paper will be sharply criticised by chiropractors, other manipulators and lobbyists of quackery. Yet I think it is an interesting and innovative approach to describe what is and is not being said on public media. The fact that chiropractors hardly ever publicly criticise or challenge each other on Twitter or elsewhere for even the most idiotic claims is, in my view, most telling.
Few people would doubt that such platforms have become hugely important in forming public opinions, and it seems safe to assume that consumers views about SMT are strongly influenced by what they read on Twitter. If we accept this position, we also have to concede that Twitter et al. are a potential danger to public health.
The survey is, however, not flawless, and the authors are the first to point that out: Given the nature of Twitter discussions and the somewhat limited access provided by Twitter’s API, it can be challenging to capture a comprehensive collection of tweets on any topic. In addition, other potential terms such as “chiro” and “spinal adjustment” are present on Twitter, which may produce datasets with somewhat different results. Finally, although December 2015 was chosen at random, there is nothing to suggest that other time frames would be significantly similar or different. Despite these limitations, this study highlights the degree to which discussions of risk and critical views on efficacy are almost completely absent from Twitter. To this I would add that a comparison subject like nursing or physiotherapy might have been informative, and that somehow osteopaths have been forgotten in the discussion.
The big question, of course, is: what can be done about creating more balance on Twitter and elsewhere? I wish I had a practical answer. In the absence of such a solution, all I can offer is a plea to everyone who is able of critical thinking to become as active as they can in busting myths, disclosing nonsense and preventing the excesses of harmful quackery.
Let’s all work tirelessly and effectively for a better and healthier future!
Low back pain (LBP) is a ‘minor complaint’ in the sense that it does not cost patients’ lives. At the same time, LBP is amongst the leading causes of disability and one of the most common reasons for patients to seek primary care. Chiropractors, osteopaths, physical therapists and general practitioners are among those treating LBP patients, but there is only limited evidence regarding the effectiveness offered by these provider groups.
The aim of this systematic review was to estimate the clinical effectiveness and to systematically review economic evaluations of chiropractic care compared to other commonly used approaches among adult patients with non-specific LBP.
A comprehensive search strategy was conducted to identify 1) pragmatic randomized clinical trials (RCTs) and/or 2) full economic evaluations of chiropractic care for low back pain compared to standard care delivered by other healthcare providers. Studies published between 1990 and 4th June 2015 were considered. The primary outcomes included pain, functional status and global improvement. Study selection, critical quality appraisal and data extraction were conducted by two independent reviewers. Data from RCTs with low risk of bias were included in a meta-analysis to determine estimates of effect sizes. Cost estimates of full economic evaluations were converted to 2015 USD and results summarized.
Six RCTs and three full economic evaluations were included. Five RCTs with low risk of bias compared chiropractic care to exercise therapy (n = 1), physical therapy (n = 3) and medical care (n = 1). The authors found similar effects for chiropractic care and the other types of care. Three low to high quality full economic evaluations studies (one cost-effectiveness, one cost-minimization and one cost-benefit) compared chiropractic to medical care. Highly divergent conclusions (favours chiropractic, favours medical care, equivalent options) were noted for economic evaluations of chiropractic care compared to medical care.
The authors drew the following conclusions: moderate evidence suggests that chiropractic care for LBP appears to be equally effective as physical therapy. Limited evidence suggests the same conclusion when chiropractic care is compared to exercise therapy and medical care although no firm conclusion can be reached at this time. No serious adverse events were reported for any type of care. Our review was also unable to clarify whether chiropractic or medical care is more cost-effective. Given the limited available evidence, the decision to seek or to refer patients for chiropractic care should be based on patient preference and values. Future studies are likely to have an important impact on our estimates as these were based on only a few admissible studies.
This is a thorough and timely review. Its results are transparent and clear, however, its conclusions are, in my view, more than a little odd.
Let me try to re-formulate them such that they are better supported by the actual data: There is no good evidence to suggest that chiropractic care is better or worse that conventional therapeutic approaches currently used for LBP. The pooled sample size dimensions too small to allow any statements about the risks of the various approaches. The data are also too weak for any pronouncements on the relative cost-effectiveness of the various options. Given these limitations, the decision which approach to use should be based on a more comprehensive analysis of the therapeutic risks.
The point I am trying to make is quite simple:
- The fact that RCTs fail to show adverse effects could be due to the small collective sample size and/or to the well-known phenomenon that, in well-controlled trials, adverse effects tend to be significantly rarer than in routine care.
- Hundreds of serious adverse events have been reported after chiropractic spinal manipulations; to these we have to add the fact that ~50% of all chiropractic patients suffer from transient, mild to moderate adverse effects after spinal manipulations.
- If we want to generate a realistic picture of the safety of a therapy, we need to include case-reports, case-series and other non-RCT evidence.
- Conventional treatments of LBP may not be free of adverse effects, but some are relatively safe.
- It seems reasonable, necessary and ethical to consider a realistic picture of the relative risks when deciding which therapy amongst equally (in)effective treatments might be best.
To me, all this seems almost painfully obvious, and I ask myself why the authors of this otherwise sound review failed to consider such thoughts. As one normally is obliged to, the authors included a section about the limitations of their review:
Our review has limitations. First, we did not search the grey literature for clinical effectiveness studies. McAuley et al. showed that the inclusion of results from the grey literature tend to decrease effectiveness estimates in meta-analyses because the unpublished studies tend to report smaller treatment effects. Second, critical appraisal requires scientific judgment that may vary among reviewers. This potential bias was minimized by training reviewers to use a standardized critical appraisal tool and using a consensus process among reviewers to reach decisions regarding scientific admissibility. Most of the original between-group differences and pooled estimates in our meta-analysis did not favour a specific provider group, and we believe it is unlikely that the inclusion of unpublished grey literature would change our conclusions. Third, the low number of clinical trials prevents us from conducting a meaningful investigation for publication bias. Fourth, the majority of the included clinical effectiveness studies (three out of five) and all three economic evaluations were conducted in the United States. Caution should therefore be used when generalizing our findings to other settings or jurisdictions. With respect to economic evaluations in particular, local healthcare systems and insurance plans may have a higher impact on cost than the type of healthcare provider.
Remarkably, this section does not mention their useless assessment of the risks with one word. Why? One answer might be found in the small-print of the paper:
The authors … have the following competing interests: MAB: Personal fees from Ordre des chiropraticiens du Québec for one teaching presentation, outside the submitted work. MJS: Position at the Nordic Institute of Chiropractic and Clinical Biomechanics is funded by the Danish Chiropractic Research Foundation. The Foundation had no role in the study design; in the design and conduct of the study, in the collection, management, analysis, and interpretation of data; in the preparation, review or approval of the manuscript; or in the decision to submit the article for publication. RBDS: Nothing to disclose. JB: Nothing to disclose. PH: Nothing to disclose. AB: Position at the School of Physical and Occupational Therapy at McGill University is funded by the Canadian Chiropractic Research Foundation. The Foundation had no role in the study design; in the design and conduct of the study, in the collection, management, analysis, and interpretation of data; in the preparation, review or approval of the manuscript; or in the decision to submit the article for publication.
At first, I thought this survey would be yet another of those useless and boring articles that currently seem to litter the literature of alternative medicine. It’s abstract seemed to confirm my suspicion: “Fifty-two chiropractors in Victoria, Australia, provided information for up to 100 consecutive encounters. If patients attended more than once during the 100 encounters, only data from their first encounter were included in this study. Where possible patient characteristics were compared with the general Australian population…” But then I saw that the chiropractors were also asked to record their patients’ main complaints. That, I thought, was much more interesting, and I decided to do a post that focusses on this particular point.
The article informs us that 72 chiropractors agreed to participate (46 % response rate of eligible chiropractors approached). During the study, 20 (28 %) of these chiropractors withdrew and did not provide any data. Fifty two chiropractors (72 % of those enrolled) completed the study, providing information for 4464 chiropractor-patient encounters. Of these, 1123 (25 %) encounters were identified as repeat patient encounters during the recording period and were removed from further analyses, leaving 3287 unique patients.
The results that I want to focus on indicated that chiropractors give the following reasons for treating patients:
- maintenance: 39%
- spinal problems: 33%
- neck problems: 18%
- shoulder problems: 6%
- headache: 6%
- hip problems: 3%
- leg problems: 3%
- muscle problems: 3%
- knee problems: 2%
(the percentage figures refer to the percentages of patients with the indicated problem)
Yes, I know, there is lots to be criticised about the methodology used for this survey. But let’s forget about this for the moment and focus on the list of reasons or indications which these chiropractors give for treating patients. For which of these is there enough evidence to justify this decision and the fees asked for the interventions? Here is my very quick run-down of the evidence:
- maintenance: no good evidence.
- spinal problems: if they mean back pain by this nebulous term, an optimist might grant that there is some promising but by no means conclusive evidence.
- neck problems: again some promising but by no means conclusive evidence.
- shoulder problems: no good evidence.
- headache: again some promising but by no means conclusive evidence
- hip problems: no good evidence.
- leg problems: no good evidence.
- muscle problems: no good evidence.
- knee problems: no good evidence.
As I said, this is merely a very quick assessment. I imagine that many chiropractors will disagree with it – and I invite them to present their evidence in the comments section below. However, if I am correct (or at least not totally off the mark), this new survey seems to show that most of the things these chiropractors do is not supported by good evidence. One could be more blunt and phrase this differently:
- these chiropractors are misleading their patients;
- they are not behaving ethically;
- they are not adhering to EBP.
Yes, we (I mean rationalists who know about EBM) did suspect this all along – but now we can back it up with quite nice data from a recent survey done by chiropractors themselves.
As has been discussed on this blog many times before, the chiropractic profession seems to be in a bit of a crisis (my attempt at a British understatement). The Australian chiropractor, Bruce Walker, thinks that, with the adoption of his ten point plan, “the chiropractic profession has an opportunity to turn things around within a generation. Importantly, it has an obligation to the public and to successive generations of chiropractors ahead of it. By embracing this plan the profession can be set on a new path, a new beginning and a new direction. This plan should be known as the new chiropractic.”
And now you are. of course, dying to hear this 10 point plan – well, here it is [heavily abbreviated, I am afraid (the footnotes [ ] and the comments referring to them are mine)]:
- There is a need to improve pre professional education for chiropractors.
Universities or private colleges?
Chiropractic education should where possible be conducted at universities  and this does not mean small single purpose institutions that are deemed universities in name only. Why is this recommended? Primarily because unlike some private colleges, government funded universities insist on intellectual evidence based rigour  in their learning and teaching and importantly require staff to be research active. Chiropractic courses need to have an underpinning pedagogy that insists that content  is taught in the context of the evidence  and that students obtain the necessary training to question and critically appraise …
Underpinning chiropractic education is program accreditation and this is also in need of review particularly where vitalistic subluxation  based courses have been legitimised by the accreditation process…
Chiropractic education should also involve specifically relevant hospital access or work experience such as hospital rounds so that students can observe patients that are truly unwell and observe the signs and symptoms taught in their theory classes. Hospital rounds would also allow chiropractic students to interact with other health providers and increase the likelihood of legitimate partnership and respect between health professions .
Who should teach chiropractic students?…
- There is a need to establish a progressive identity.
Chiropractors need to become solely musculoskeletal practitioners with a special emphasis on spinal pain . If the profession becomes the world’s experts in this area it will command the respect deserved . Importantly it will not be seen as a collective of alternative medicine practitioners with a strange belief system …
- The profession should develop a generalised special interest.
…Chiropractic as a profession should also develop a special interest area in the health sciences that can make a worldwide contribution to other related health sciences. This could be either research based or clinically based or indeed both. Some possibilities are: the further development and refinement of evidence based practice , improved posture through motor control, musculoskeletal care for the aged and elderly, improving bone density or the very important area of translating research into practice via implementation science. Whatever chosen we need to develop a special interest that sets us apart as experts in a distinctive area .
- Marginalisation of the nonsensical elements within the profession.
As professionals chiropractors should not tolerate colleagues or leadership in the profession who demonstrate aberrant ideas. If colleagues transgress the boundaries or professionalism they should be reported to authorities and this should be followed up with action by those authorities …
- The profession and individual practitioners should be pro public health.
It is important to speak up openly in favour of evidence-based public health measures and to join public health associations and agencies … For example, chiropractors promoting anti-vaccination views need to be countered …
- Support legitimate organised elements of the profession.
Practitioners should support and become involved in chiropractic organisations that are clearly ethical and evidence based  and add value to them…
…Regular collective professional advertising of the benefits of chiropractic for back pain, for example, is a worthy undertaking but the advertisements or media offerings must be evidence based .
- The profession should strive to improve clinical practice.
Chiropractors contribute to the public health by the aggregated benefit of positive outcomes to health from their clinical practices … Where restrictive practice laws relating to chiropractors prescribing medication exist the profession should seek to overturn them …
- The profession should embrace evidence based practice.
EBP is the amalgam of best scientific evidence plus clinical expertise plus patient values and circumstances. So what could be missing from this equation? It is clear that in the opinion of a sizable minority of the profession the elements that are missing are “practitioner ideology” and “practitioner values and circumstances”. These additional self- serving and dangerous notions should not be entertained. The adoption of evidence based practice is critical to the future of chiropractic and yet there is resistance by elements within the profession. Soft resistance occurs with attempts to change the name of “Evidence-based practice” (EBP) to “Evidence-informed practice” (EIP). It is worth noting that currently there are over 13,000 articles listed in PUBMED on EBP but less than 100 listed on EIP. So why are some of our profession so keen to use this alternate and weaker term?
Hard resistance against EBP occurs where it is stated that the best evidence is that based on practice experience and not research. This apparently is known as Practice Based Evidence (PBE) and has a band of followers …
- The profession must support research.Research needs to become the number one aspiration of the profession. Research informs both practice and teaching. Without research the profession will not progress. Sadly, the research contribution by the chiropractic profession can only be described as seed like. Figure 1 is a comparison of articles published in the past 45 years by decade using the key words “Physiotherapy” or “Physical Therapy” versus “Chiropractic” (source PUBMED). The Y axis is the number of articles published and the X axis is the decade, the red represents physiotherapy articles, the blue chiropractic. The difference is stark and needs urgent change .If the profession at large ignores research whether in its conduct, administration or its results the profession will wither on the vine …
- Individual chiropractors need to show personal leadership to effect change.
Change within the profession will likely only occur if individual chiropractors show personal leadership….
As part of this personal leadership it will be critical to speak out within the profession. Speak out and become a mentor to less experienced colleagues …
Anyone you thinks that with such a strategy “the chiropractic profession has an opportunity to turn things around within a generation” is, in my view, naïve and deluded. The 10 points are not realistic and woefully incomplete. The most embarrassing omission is a clear statement that chiropractors are fully dedicated to making sure that they serve the best interest of their patients by doing more good than harm.