MD, PhD, FMedSci, FSB, FRCP, FRCPEd

chiropractic

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I have argued since many years that pharmacists should not be selling or promoting homeopathic and other remedies for which there is no proof of efficacy – the last time I published my view on this matter is even less than a week ago: Personally, I would go another step further and remind pharmacists who sell homeopathic remedies to the unsuspecting public that it is unethical to pretend they are more than placebos.

Despite my insistence and despite the fact that many agree with me (at least privately), there are precious few pharmacists who actually do something meaningful about the current situation. And there is very little visible change: in the UK, it is currently hard to find a pharmacy where homeopathic remedies are not on the shelves, and certainly all the major chains seem to put money before health care ethics.

I am, of course, speaking about the situation in the UK, France, Germany and some other European countries. Perhaps elsewhere things are different?

A NZ website seems to indicate that ‘down under’ the pharmacists are getting more active. Some strongly argue against unproven or disproven remedies in pharmacies:

Firstly, …it’s not a case that “pharmacists ‘should’ only be selling health products for which there is credible evidence of efficacy” (alterations mine, emboldened) but that they are obliged to—but choose not to. Their ethical guidelines state -

[PHARMACISTS] MUST:… Only purchase, supply or promote any medicine, complementary therapy, herbal remedy or other healthcare product where there is no reason to doubt its quality or safety and when there is credible evidence of efficacy.

…Secondly, the argument that ‘other businesses sell junk remedies therefore we shall’ is unsound. One of the key points about the ethical regulations for pharmacies is that customers should be able to walk into a store and have an expectation that the remedies within the store are basically sound. If other businesses elect to be unsound, that’s poor health practice, but no justification to do likewise. On the face of it, it would seem that the profit motive is ruling over sound and ethical practice.

Thirdly, that some GPs subscribe placebos should have no standing in this. There is some arguments for GPs to prescribe placebo remedies in some cases; others would argue that education is a better response in most cases. Either way—and just my opinion—it seems to me that GPs prescribing homeopathic remedies encourages people to think these have real remedial effects. I don’t work within the industry, but I am sure are ways of offering placebos that avoid using off-the-shelf commercial products. One might be that patients only get placebo ‘treatments’ via prescription.

…Fourthly, Pharmacy Today encourages that “pharmacies need to reconsider their stance in the light of this report”***. While this is an excellent idea, and one I thoroughly support, I suspect the underlying driver isn’t the report, but media presence on the topic. There is a long trail of evidence over many years showing that homeopathic remedies are not effective for anything.

The Australian study*** that prompted the latest round of interest drew this statement,

Based on the assessment of the evidence of effectiveness of homeopathy, NHMRC concludes that there are no health conditions for which there is reliable evidence that homeopathy is effective.

Homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness. People who are considering whether to use homeopathy should first get advice from a registered health practitioner.* Those who use homeopathy should tell their health practitioner and should keep taking any prescribed treatments.

The National Health and Medical Research Council expects that the Australian public will be offered treatments and therapies based on the best available evidence.

…Why were the relevant professional bodies not onto this evidence sooner?…

GOOD QUESTION!

I might add another one: why are the European professional bodies of pharmacy doing so little about this ongoing breach of their own ethical codes?

(*** the report that the author refers to is the one by the Australian National Health and Medical Research Council we discussed on this blog a few days ago.)

Chiropractors like to promote themselves as primary healthcare professionals. But are they? A recent survey might go some way towards addressing this question. It was based on a cross sectional online questionnaire distributed to 4 UK chiropractic associations. The responses were collected over a period of two months from March 26th 2012 to May 25th 2012.

Of the 2,448 members in the 4 participating associations, 509 chiropractors (~21%) completed the survey. The results of the survey show that the great majority of UK chiropractors surveyed reported evaluating and monitoring patients in regards to posture (97.1%), inactivity/overactivity (90.8%) and movement patterns (88.6%). Slightly fewer provided this type of care for psychosocial stress (82.3%), nutrition (74.1%) and disturbed sleep (72.9%). Still fewer did so for smoking (60.7%) and over-consumption of alcohol (56.4%). Verbal advice given by the chiropractor was reported as the most successful resource to encourage positive lifestyle changes as reported by 68.8% of respondents. Goal-setting was utilised by 70.7% to 80.4% of respondents concerning physical fitness issues. For all other lifestyle issues, goal-setting was used by approximately two-fifths (41.7%) or less. For smoking and over-consumption of alcohol, a mere one-fifth (20.0% and 20.6% respectively) of the responding chiropractors set goals.

The authors of this survey concluded that UK chiropractors are participating in promoting positive lifestyle changes in areas common to preventative healthcare and health promotion areas; however, more can be done, particularly in the areas of smoking and over-consumption of alcohol. In addition, goal-setting to support patient-provider relationships should be more widespread, potentially increasing the utility of such valuable advice and resources.

When I saw that a new UK-wide survey of chiropractic has become available, I had great expectations. Sadly, they were harshly disappointed. I had hoped that, after going to the considerable trouble of setting up a nationwide survey of this nature, we would have some answers to the most urgent questions that currently plague chiropractic and are amenable to study by survey. In my view, some of these questions include:

  • How many chiropractors actually see themselves as primary care professionals?
  • What conditions do chiropractors treat?
  • Specifically how many of them believe they can treat non-spinal conditions effectively?
  • How many chiropractors regularly treat children?
  • For which conditions?
  • How many patients get X-rayed by chiropractors?
  • How many are in favour of vaccinations?
  • How many are aware of adverse effects of spinal manipulation?
  • How chiropractors obtain informed consent before starting treatment?
  • What percentage of chiropractors use spinal manipulation?
  • What other treatments are used how often?
  • How often do chiropractors advise their patients about medications prescribed by real doctors?
  • How often do they refer patients to other health care providers?

All of these questions are highly relevant and none of them has recently been studied. But, sadly, the new paper does not answer them. Why? As I see it, there are several possibilities:

  • Chiropractors do not find these questions as relevant as I do.
  • They do not want to know the answers.
  • They do not like to research issues that might shine a bad light on them.
  • They view research mostly as a promotional exercise.
  • They did research (some of) these questions but do not dare to publish the results.
  • They will publish the results in a separate paper.

It would be interesting to hear from the authors which possibility applies.

Henry Louis Mencken (1880-1956) was an outspoken American journalist, essayist and literary critic famous for his vitriolic attacks on what he considered to be the hypocrisy of much of American life. In 1924, he published an essay on chiropractic which, I think, is still poignant today. I take the liberty of reproducing here in a slightly abbreviated form.

This preposterous quackery [chiropractic] flourishes lushly in the back reaches of the Republic, and begins to conquer the less civilized folk of the big cities. As the old-time family doctor dies out in the country towns, with no competent successor willing to take over his dismal business, he is followed by some hearty blacksmith or ice-wagon driver, turned into a chiropractor in six months, often by correspondence… [Chiropractic] pathology is grounded upon the doctrine that all human ills are caused by pressure of misplaced vertebrae upon the nerves which come out of the spinal cord — in other words, that every disease is the result of a pinch. This, plainly enough, is buncombe. The chiropractic therapeutics rest upon the doctrine that the way to get rid of such pinches is to climb upon a table and submit to a heroic pummeling by a retired piano-mover. This, obviously, is buncombe doubly damned.

…Any lout with strong hands and arms is perfectly equipped to become a chiropractor. No education beyond the elements is necessary. The takings are often high, and so the profession has attracted thousands of recruits — retired baseball players, work-weary plumbers, truck-drivers, longshoremen, bogus dentists, dubious preachers, cashiered school superintendents. Now and then a quack of some other school — say homeopathy — plunges into it. Hundreds of promising students come from the intellectual ranks of hospital orderlies.

…[The chiropractor’s] trade is mainly with ambulant patients; they must come to his studio for treatment. Most of them have lingering diseases; they tour all the neighborhood doctors before they reach him. His treatment, being nonsensical, is in accord with the divine plan. It is seldom, perhaps, that he actually kills a patient, but at all events he keeps any a worthy soul from getting well.

…But chiropractic, of course, is not perfect. It has superb potentialities, but only too often they are not converted into concrete cadavers. The hygienists rescue many of its foreordained customers, and, turning them over to agents of the Medical Trust, maintained at the public expense, get them cured. Moreover, chiropractic itself is not certainly fatal: even an Iowan with diabetes may survive its embraces. Yet worse, I have a suspicion that it sometimes actually cures. For all I know (or any orthodox pathologist seems to know) it may be true that certain malaises are caused by the pressure of vagrant vertebra upon the spinal nerves. And it may be true that a hearty ex-boilermaker, by a vigorous yanking and kneading, may be able to relieve that pressure. What is needed is a scientific inquiry into the matter, under rigid test conditions, by a committee of men learned in the architecture and plumbing of the body, and of a high and incorruptible sagacity. Let a thousand patients be selected, let a gang of selected chiropractors examine their backbones and determine what is the matter with them, and then let these diagnoses be checked up by the exact methods of scientific medicine. Then let the same chiropractors essay to cure the patients whose maladies have been determined. My guess is that the chiropractors’ errors in diagnosis will run to at least 95% and that their failures in treatment will push 99%. But I am willing to be convinced.

Where is there is such a committee to be found? I undertake to nominate it at ten minutes’ notice. The land swarms with men competent in anatomy and pathology, and yet not engaged as doctors. There are thousands of hospitals, with endless clinical material. I offer to supply the committee with cigars and music during the test. I offer, further, to supply both the committee and the chiropractors with sound wet goods. I offer, finally, to give a bawdy banquet to the whole Medical Trust at the conclusion of the proceedings.

I imagine that most chiropractors would find this comment rather disturbing. However, I do like it for several reasons:

  • it is refreshingly politically incorrect; today journalists seem to be obsessed with the notion of ‘balance’ thus often creating the impression that there are two valid sides to an issue where, in fact, there is only one;
  • it gets right at the heart of several problems which have plagued chiropractic from its beginning;
  • it even suggests a way to establishing the truth about the value of chiropractic which could easily been followed some 90 years ago;
  • finally it predicts a result of such a test – and I would not be surprised, if it turned out to be not far from the truth.

Please let me know what you think, regardless of whether you are a chiropractor or not.

The UK Professional Standards Authority for Health and Social Care (PSA) tries to promote the health, safety and wellbeing of patients, service users and the public by raising standards of regulation and voluntary registration of people working in health and care. They are an independent body, accountable to the UK Parliament.

In July 2014, the PSA audited all 75 of the cases that the General Chiropractic Council (GCC) had closed at the initial stages of its fitness to practise (FTP) process during the 12 month period from 1 June 2013 to 30 May 2014. The final verdict of the PSA’s audit seems devastating. Here is a short excerpt from the conclusions of its report:

The extent of the deficiencies we found in this audit (as set out in detail above) which related to failures across every aspect of the casework framework, as well as widespread failures to comply with the GCC’s own procedures, raises concern about the extent to which the public can have confidence in the GCC’s operation of its initial stages FTP process.

In summary, the particular areas of failures/weaknesses identified in our audit include:

  • Ineffective screening on receipt of ‘complaints’ and inconsistent completion and updating of risk assessments
  • Customer service issues, including failing to respond to/acknowledge correspondence promptly, failing to provide clear information about the FTP process and failing to provide updates about progress and outcomes within reasonable timeframes
  • Inadequate investigation of cases through failures to gather or validate relevant evidence or to do so promptly – sometimes as a result of inconsistent and ineffective use of case plans and case reviews
  • Deficiencies in the evaluation of information by decision-makers and weaknesses in the reasoning provided for decisions, including failures to address all the relevant allegations and/or reaching decisions on the basis of insufficient evidence
  • Poor record keeping and various data protection breaches or potential breaches
  • Ineffective systems for the sharing of relevant information between the Registration and FTP teams, leading to inappropriate action being taken in some cases
  • Widespread non-compliance with internal guidance and procedures.

We have also concluded that the steps taken by the GCC, in particular the processes it introduced in its procedure manual in February had not at the time of the audit resulted in consistent improvement in the quality of its casework.

What does all of this mean?

The GCC’s website informs us that this organisation regulates all chiropractors in the UK to ensure the safety of patients undergoing chiropractic treatment. The GCC is an independent statutory body established by Parliament to regulate the chiropractic profession. We protect the health and safety of the public by ensuring high standards of practice in the chiropractic profession. The title of ‘chiropractor’ is protected by law and it is a criminal offence for anyone to describe themselves as any sort of chiropractor without being registered with the GCC.  We check that all chiropractors are properly qualified and are fit to practise.

The conclusions of the PSA audit seem to indicate nothing less than this: the GCC is not fit for purpose!

I have often said that the regulation of nonsense must inevitably result in nonsense – but I did not expect to get a confirmation from the GCC in this fashion.

Neck pain is a common problem which often causes significant disability. Chiropractic manipulation has become one of the most popular forms of alternative treatment for such symptoms. This seems surprising considering that neck manipulations are neither convincingly effective nor free of adverse effects.

The current Cochrane review on this subject could not be clearer: “Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior.” In the absence of compelling evidence for efficacy, any risk of neck manipulation would tilt the risk/benefit balance into the negative.

Adverse effects of neck manipulations range from mild symptoms, such as local neck tenderness or stiffness, to more severe injuries involving the spinal cord, peripheral nerve roots, and arteries within the neck. A recent paper reminds us that another serious complication has to be added to this already long list: phrenic nerve injury.

The phrenic nerve is responsible for controlling the contractions of the diaphragm, which allows the lungs to take in and release air and make us breathe properly. The phrenic nerve is formed from C3, C4, and C5 nerve fibres and descends along the anterior surface of the scalenus anterior muscle before entering the thorax to supply motor and sensory input to the diaphragm. Its anatomic location in the neck leaves it vulnerable to traumatic injury. Phrenic nerve injury can result in paralysis of the diaphragm and often leads to deteriorating function of the diaphragm, which can lead to partial or complete paralysis of the muscle and, as a result, serious breathing problems.

Patients who experience such problems may require emergency medical treatment or surgery. Sudden, severe damage to the phrenic nerve can make it impossible for the diaphragm to contract on its own. In order to make sure that the patient can breathe, a breathing tube needs to be inserted, a process called intubation. Artificial respiration would then be required.

American neurologists published a case report of a healthy man who consulted a chiropractor for his neck pain. Predictably, the chiropractor employed cervical manipulation to treat this condition. The result was bilateral diaphragmatic paralysis.

Similar cases have been reported previously, for instance, here and here and here and here. Damage to other nerves has also been documented to be a possible complication of spinal manipulation, for instance, here and here.

The authors of this new case report conclude that physicians must be aware of this complication and should be cautious when recommending spinal manipulation for the treatment of neck pain, especially in the presence of preexisting degenerative disease of the cervical spine.

I know what my chiropractic friends will respond to this post:

  • I am alarmist,
  • I cherry-pick articles that are negative for their profession,
  • these cases are extreme rarities,
  • conventional medicine is much more dangerous.

To this I reply: Imagine a conventional therapy about which the current Cochrane review says that it has no proven effect for the condition in question. Imagine further that this therapy causes mild to moderate adverse effects in about 50% of all patients in addition to very dramatic complications which are probably rare but, as no monitoring system exists, of unknown frequency. Imagine now that the professionals using this treatment more regularly than any other clinicians steadfastly deny that the risk/benefit balance is way out of kilter.

Would you call someone who repeatedly tries to warn the public of this situation ‘alarmist’?

Would you not consider the professionals who continue to practice the therapy in question to be irresponsible?

A recent article from THE CHIROPRACTIC REPORT entitled ‘Media Criticism – Whether and How to Respond’ has caught my attention. It provides detailed and, in my view, quite remarkable advice to chiropractors as to how they should react to criticism. Here is an excerpt:

…the easiest media comment to challenge is one that makes an absolute claim – for example Salzberg’s claim that the practice of chiropractic is “highly dubious.” It also means that an effective response should usually not be absolute – claiming for example that chiropractic care can cure, or a specific chiropractic treatment is proven effective for, a specific condition.

Let’s explore this with an example. In 2008 a British journalist, Simon Singh, while promoting a new book he had co-authored that was heavily critical of chiropractic and complementary and alternative medicine in general, wrote an article in the Guardian newspaper in which he claimed that “there is not a jot of evidence” that chiropractic treatment can help children with “colic, sleeping and feeding problems . . . and prolonged crying.” In other words, a black and white claim.

There was and is evidence. Singh was wrong. How might you respond to this? Here are your options for reply, from the outspoken to the restrained:

a. Chiropractic is proven effective for the cure of infantile colic.

b. Spinal manipulation is proven effective for the cure of infantile colic

c. Manual treatments are proven effective for the cure of infantile colic

d. Chiropractic/spinal manipulation/ manual therapies may be effective in reducing the symptoms of infantile colic.

e. Where spinal joint dysfunction/subluxation is found, chiropractic/spinal manipulation/manual therapies may be effective in reducing abnormal and incessant crying in infants medically diagnosed as having infantile colic

f. Chiropractic care has a central focus of assessing and correcting spinal joint dysfunction/subluxation and its biomechanical and physiological effects, and where these are addressed many symptoms may be reduced including those associated with infantile colic.

The first three options are as black and white as Singh’s statement, and are not supported by the evidence. Some studies say yes, some no. All the other options, which have appropriate qualifiers and shades of gray, are supported by sound evidence.

Much of that evidence is referred to and referenced in the March 2010 issue of this Report, available online at www.chiropracticreport.com/pastissues. To answer Singh effectively one only has to produce some of the good quality research and question how he can be credible when he says “there is not a jot of evidence”.

With respect to evidence, in this context that means evidence published in peer-reviewed scientific journals. You may decide to comment on one or more anecdotal case reports from your practice to give your response greater human interest, but this will mean nothing unless supported by higher levels of published evidence.

Am I the only one to find this remarkable?

Am I wrong in interpreting this as detailed instructions to mislead the public?

Are these instructions not merely advice to defend chiropractic commercial interests at the expense of public health?

How can this be ethical?

How often have we heard it on this blog and elsewhere?

  • chiropractic is progressing,
  • chiropractors are no longer adhering to their obsolete concepts and bizarre beliefs,
  • chiropractic is fast becoming evidence-based,
  • subluxation is a thing of the past.

American chiropractors wanted to find out to what extent these assumptions are true and collected data from chiropractic students enrolled in colleges throughout North America. The stated purpose of their study is to investigate North American chiropractic students’ opinions concerning professional identity, role and future.

A 23-item cross-sectional electronic questionnaire was developed. A total of 7,455 chiropractic students from 12 North American English-speaking chiropractic colleges were invited to complete the survey. Survey items encompassed demographics, evidence-based practice, chiropractic identity and setting, and scope of practice. Data were collected and descriptive statistical analyses were performed.

A total of 1,243 questionnaires were electronically submitted. This means the response rate was 16.7%. Most respondents agreed (34.8%) or strongly agreed (52.2%) that it is important for chiropractors to be educated in evidence-based practice. A majority agreed (35.6%) or strongly agreed (25.8%) the emphasis of chiropractic intervention is to eliminate vertebral subluxations/vertebral subluxation complexes. A large number of respondents (55.2%) were not in favor of expanding the scope of the chiropractic profession to include prescribing medications with appropriate advanced training. Most respondents estimated that chiropractors should be considered mainstream health care practitioners (69.1%). About half of all respondents (46.8%) felt that chiropractic research should focus on the physiological mechanisms of chiropractic adjustments.

The authors of this paper concluded that the chiropractic students in this study showed a preference for participating in mainstream health care, report an exposure to evidence-based practice, and desire to hold to traditional chiropractic theories and practices. The majority of students would like to see an emphasis on correction of vertebral subluxation, while a larger percent found it is important to learn about evidence-based practice. These two key points may seem contradictory, suggesting cognitive dissonance. Or perhaps some students want to hold on to traditional theory (e.g., subluxation-centered practice) while recognizing the need for further research to fully explore these theories. Further research on this topic is needed.

What should we make of these findings? The answer clearly must be NOT A LOT.

  • the response rate was dismal,
  • the questionnaire was not validated
  • there seems to be little critical evaluation or discussion of the findings.

If anything, these findings seem to suggest that chiropractors want to join evidence based medicine, but on their own terms and without giving up their bogus beliefs, concept and practices. They seem to want the cake and eat it, in other words. The almost inevitable result of such a development would be that real medicine becomes diluted with quackery.

Much has been written on this blog about progress in the area of chiropractic practice and research. But where is the evidence for progress? I did a little search and one of the first sites I stumbled across was this one which is full to bursting with bogus claims. This cannot be what chiropractors call ‘progress’, I thought.

Determined to find real progress, I continued searching and found THE FOUNDATION FOR CHIROPRACTIC PROGRESS. Great, I thought, an organisation and a website entirely devoted to the very subject I was looking for. Consequently, I studied the information provided here in some detail. What follows are excerpts from the site:

Chiropractic care is a health option that has proven beneficial for a multitude of health conditions, along with in the practice of achieving optimal wellness. It is essential for those unaware of chiropractic care to be adequately informed, so they too can experience the benefits that over 60,000 practicing doctors of chiropractic in the U.S. provide to their patients daily. Established in 2003, the not-for-profit Foundation for Chiropractic Progress (F4CP) aims to educate the public about the many benefits associated with chiropractic care.On behalf of the F4CP, I invite you to tour this site and learn more about this effective form of treatment.
Kind regards,
Kent Greenawalt
Chairman | Foundation for Chiropractic Progress
THIS WAS A STRANGE INTRODUCTION, I THOUGHT; BUT UNDETERRED I READ ON:
Parents of Colicky Infants Turn to Chiropractic Care

For those parents who never imagined their ailing babies and toddlers could be helped by chiropractic care, it may be time for some rethinking.New mom Jean, a 31-year-old speech therapist from New Jersey, became an advocate after enlisting the help of her own chiropractor to treat her colicky infant girl, Emma. After having had what she says was “no luck” with the usual ways of alleviating colic symptoms – including giving Emma children’s probiotics daily – one appointment with board-certified in chiropractic pediatrics Dr. Lora Tanis produced an immediate difference.

Concussions Among Athletes

A concussion is a type of traumatic brain injury caused by a bump, blow or jolt to the head that can change the way the brain functions. Symptoms include dizziness, instability and confusion.

Using methods that rely on brain-based, non-invasive, drugfree approaches — like chiropractic
care and physical rehab — can help re-establish balance and maximal brain and nervous system functionality.

News of Health – Improving Military Health Care

Retired U.S. Army Brigadier General Becky Halstead—the first woman in U.S. history to command in combat at the strategic level—is speaking out on the value of chiropractic care for the nation’s military men and women.

Good Health

With the epidemic now estimated to be costing the nation $147 billion annually, it’s a question that’s very much on the minds of health experts. And many, including lifestyle guru Shea Vaughn, are citing chiropractic care as a crucial part of overall wellness programs.

FEELING A LITTLE DISAPPOINTED, I STOPPED READING AND THOUGHT

PROGRESS INDEED !!!

Few subjects lead to such heated debate as the risk of stroke after chiropractic manipulations (if you think this is an exaggeration, look at the comment sections of previous posts on this subject). Almost invariably, one comes to the conclusion that more evidence would be helpful for arriving at firmer conclusions. Before this background, this new publication by researchers (mostly chiropractors) from the US ‘Dartmouth Institute for Health Policy & Clinical Practice’ is noteworthy.

The purpose of this study was to quantify the risk of stroke after chiropractic spinal manipulation, as compared to evaluation by a primary care physician, for Medicare beneficiaries aged 66 to 99 years with neck pain.

The researchers conducted a retrospective cohort analysis of a 100% sample of annualized Medicare claims data on 1 157 475 beneficiaries aged 66 to 99 years with an office visit to either a chiropractor or to a primary care physician for neck pain. They compared hazard of vertebrobasilar stroke and any stroke at 7 and 30 days after office visit using a Cox proportional hazards model. We used direct adjusted survival curves to estimate cumulative probability of stroke up to 30 days for the 2 cohorts.

The findings indicate that the proportion of subjects with a stroke of any type in the chiropractic cohort was 1.2 per 1000 at 7 days and 5.1 per 1000 at 30 days. In the primary care cohort, the proportion of subjects with a stroke of any type was 1.4 per 1000 at 7 days and 2.8 per 1000 at 30 days. In the chiropractic cohort, the adjusted risk of stroke was significantly lower at 7 days as compared to the primary care cohort (hazard ratio, 0.39; 95% confidence interval, 0.33-0.45), but at 30 days, a slight elevation in risk was observed for the chiropractic cohort (hazard ratio, 1.10; 95% confidence interval, 1.01-1.19).

The authors conclude that, among Medicare B beneficiaries aged 66 to 99 years with neck pain, incidence of vertebrobasilar stroke was extremely low. Small differences in risk between patients who saw a chiropractor and those who saw a primary care physician are probably not clinically significant.

I do, of course, applaud any new evidence on this rather ‘hot’ topic – but is it just me, or are the above conclusions a bit odd? Five strokes per 1000 patients is definitely not “extremely low” in my book; and furthermore I do wonder whether all experts would agree that a doubling of risk at 30 days in the chiropractic cohort is “probably not clinically significant” – particularly, if we consider that chiropractic spinal manipulation has so very little proven benefit.

My message to (chiropractic) researchers is simple: PLEASE REMEMBER THAT SCIENCE IS NOT A TOOL FOR CONFIRMING BUT FOR TESTING HYPOTHESES.

On 1/12/2014 I published a post in which I offered to give lectures to students of alternative medicine:

Getting good and experienced lecturers for courses is not easy. Having someone who has done more research than most working in the field and who is internationally known, might therefore be a thrill for students and an image-boosting experience of colleges. In the true Christmas spirit, I am today making the offer of being of assistance to the many struggling educational institutions of alternative medicine .

A few days ago, I tweeted about my willingness to give free lectures to homeopathic colleges (so far without response). Having thought about it a bit, I would now like to extend this offer. I would be happy to give a free lecture to the students of any educational institution of alternative medicine.

I did not think that this would create much interest – and I was right: only the ANGLO-EUROPEAN COLLEGE OF CHIROPRACTIC has so far hoisted me on my own petard and, after some discussion (see comment section of the original post) hosted me for a lecture. Several people seem keen on knowing how this went; so here is a brief report.

I was received, on 14/1/2015, with the utmost kindness by my host David Newell. We has a coffee and a chat and then it was time to start the lecture. The hall was packed with ~150 students and the same number was listening in a second lecture hall to which my talk was being transmitted.

We had agreed on the title CHIROPRACTIC: FALLACIES AND FACTS. So, after telling the audience about my professional background, I elaborated on 7 fallacies:

  1. Appeal to tradition
  2. Appeal to authority
  3. Appeal to popularity
  4. Subluxation exists
  5. Spinal manipulation is effective
  6. Spinal manipulation is safe
  7. Ad hominem attack

Numbers 3, 5 and 6 were dealt with in more detail than the rest. The organisers had asked me to finish by elaborating on what I perceive as the future challenges of chiropractic; so I did:

  1. Stop happily promoting bogus treatments
  2. Denounce obsolete concepts like ‘subluxation’
  3. Clarify differences between chiros, osteos and physios
  4. Start a culture of critical thinking
  5. Take action against charlatans in your ranks
  6. Stop attacking everyone who voices criticism

I ended by pointing out that the biggest challenge, in my view, was to “demonstrate with rigorous science which chiropractic treatments demonstrably generate more good than harm for which condition”.

We had agreed that my lecture would be followed by half an hour of discussion; this period turned out to be lively and had to be extended to a full hour. Most questions initially came from the tutors rather than the students, and most were polite – I had expected much more aggression.

In his email thanking me for coming to Bournemouth, David Newell wrote about the event: The general feedback from staff and students was one of relief that you possessed only one head, :-). I hope you may have felt the same about us. You came over as someone who had strong views, a fair amount of which we disagreed with, but that presented them in a calm, informative and courteous manner as we did in listening and discussing issues after your talk. I think everyone enjoyed the questions and debate and felt that some of the points you made were indeed fair critique of what the profession may need to do, to secure a more inclusive role in the health care arena.

 
As you may have garnered from your visit here, the AECC is committed to this task as we continue to provide the highest quality of education for the 21st C representatives of such a profession. We believe centrally that it is to our society at large and our communities within which we live and work that we are accountable. It is them that we serve, not ourselves, and we need to do that as best we can, with the best tools we have or can develop and that have as much evidence as we can find or generate. In this aim, your talk was important in shining a more ‘up close and personal’ torchlight on our profession and the tasks ahead whilst also providing us with a chance to debate the veracity or otherwise of yours and ours differing positions on interpretation of the evidence.

My own impression of the day is that some of my messages were not really understood, that some of the questions, including some from the tutors, seemed like coming from a different planet, and that people were more out to teach me than to learn from my talk. One overall impression that I took home from that day is that, even in this college which prides itself of being open to scientific evidence and unimpressed by chiropractic fundamentalism, students are strangely different from other health care professionals. The most tangible aspect of this is the openly hostile attitude against drug therapies voiced during the discussion by some students.

The question I always ask myself after having invested a lot of time in preparing and delivering a lecture is: WAS IT WORTH IT? In the case of this lecture, I think the answer is YES. With 300 students present, I am fairly confident that I did manage to stimulate a tiny bit of critical thinking in a tiny percentage of them. The chiropractic profession needs this badly!

 

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