We all remember the libel case of the British Chiropractic Association (BCA) against Simon Singh, I’m sure. The BCA lost, and the chiropractic profession was left in disarray.
One would have thought that chiropractors have learnt a lesson from this experience which, after all, resulted in a third of all UK chiropractors facing disciplinary proceedings. One would have thought that chiropractors had enough of their attempts to pursue others when, in fact, they themselves were clearly in the wrong. One would have thought that chiropractors would eventually focus on providing us with some sound evidence about their treatments. One would have thought that chiropractors might now try to get their act together.
Yet it seems that such hopes are being sorely disappointed. In particular, chiropractors continue to attack those who have the courage to publicly criticise them. The proof for this statement is that, during the last few months, chiropractors took direct or indirect actions against me on three different occasions.
The first complaint was made by a chiropractor to the PRESS COMPLAINTS COMMISSION (PCC). The GUARDIAN had commented on a paper that I had just published which demonstrated that many trials of chiropractic fail to mention adverse effects. If nothing else, this omission amounts to a serious breach of publication ethics and is thus not a trivial matter. However, the chiropractor felt that the GUARDIAN and I were essentially waging a war against chiropractors in order to tarnish the reputation and public image of chiropractors. The PCC considered the case and promptly dismissed it.
The second complaint was made by a local chiropractor to my university. He alleged that I had been generally unfair in my publications on the subject and, specifically, he claimed that, in a recent systematic review of deaths after chiropractic treatments, I had committed what he called “research misconduct”. My university considered the case and promptly dismissed it.
The third and probably most significant complaint was also made by a chiropractor directly to my university. This time, the allegation was that I had fabricated data in an article published as long ago as 1996. The chiropractor in question had previously already tried three times to attack me through complaints and through his publications. Crucially, several years ago he had filed a formal complaint with the General Medical Council (GMC) claiming that, in my published articles, I systematically and wilfully misquoted the chiropractic literature. At the time, the GMC had ruled that his accusation had been unfounded.
Presumably to increase his chances of success for his fourth attempt, his new complaint to my university was backed up by a supporting letter from the WORLD FEDERATION OF CHIROPRACTIC. This document stated that my publications relating to the risks of chiropractic had “serious scientific shortcomings” and suggested that Exeter University “publicly distance itself from Prof Ernst’s publications on chiropractic, to enhance the reputation of the university”. My university peers considered the case and promptly dismissed it.
At this point, I should perhaps explain that my university has, in the past, been less than protective towards me. During the last decade or so, complaints angainst me had become a fairly regular occurrence, and invariably, my peers have taken them very seriously. When the first private secretary of Charles Windsor filed one, they even deemed it appropriate to conduct an official 13 month long investigation into my alleged wrong-doings. Thus my peers’ dismissal of the two chiropractors’ claims indicates to me that their two recent complaints must have been truly and utterly devoid of substance.
The three deplorable episodes summarised here speak for themselves, I think. I will therefore abstain from further comments and am delighted to leave this task to the readers of this blog.
205 Responses to Chiropractic: lessons that have not been learnt?
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I have no knowledge of the truth/untruth of any accusations. I think it most unfortunate in the fields of scientific inquiry that researchers and practitioners may not simply let the facts and outcomes speak for themselves but continue to indulge their tempers in an unseemly fashion. Let the sunlight shine on the truth, and the vipers head for the deep caves.
I have no knowledge of the truth/untruth of any of the above accusations. I think it most unfortunate in the fields of scientific inquiry that researchers and practitioners may not simply let the facts and outcomes speak for themselves but continue to indulge their tempers in an unseemly fashion. Let the sunlight shine on the truth, and the vipers head for the deep caves.
It seems that British chiropractors might be very different than American ones. Around here, you go to a chiropractor and say “Hey, my back hurts” and he says “OK, let me check you for serious medical issues… no? Alrighty then, let me push on the back here a little” and you say “gee thanks that feels much better!” and go home.
The chiropractors I’ve known don’t make any magical claims, it’s pretty much the same as paying for a massage, except they do that initial look-see to make sure you don’t have an obvious degenerated disk or shattered vertebrae or something before they work on you. By contrast, with a masseur you just get worked on, and if you’ve got a spinal condition that causes you to die or something, tough luck, you got what you paid for.
I go to a chiropractor when my back or neck hurts and he fixes it for me without drugs or surgery, and it’s much quicker than massage for pretty much the same cost and same result.
..dude, a physio on the NHS would have the same effect, likely know more about what they are doing and be far more able to advise you to help with future issues than a chiropractor with no real medical training or evidence that what they are doing helps you, other than “my back feels better for a while”, and all for free…
“dude, a physio on the NHS would have the same effect, likely know more about what they are doing and be far more able to advise you to help with future issues than a chiropractor with no real medical training or evidence that what they are doing helps you, other than “my back feels better for a while”, and all for free…”
Can’t comment on the education requirements for chiropractors in the UK but I would assume they are very similar to that which we receive in Canada. As a practicing chiropractor in Ontario Canada, I have four years of an undergraduate degree in Kinesiology plus fours years training in anatomy dissection, biomechanics, biochemistry and nutrition, x-ray technique and interpretation and lots of other medical courses. I really don’t understand where these people get the misconception that a)chiropractors have no real medical training and b) that there exists little to no evidence to back up the results. Please refer below
http://www.aaos.org/news/aaosnow/mar08/youraaos10.asp
journals.lww.com › Home › February 15, 2008 – Volume 33 – Issue 4S
New Zealand acute low back pain guide, incorporating the … – ACC
… and hundreds more from reputable sources. Please before you go spreading hate and slander a profession, go educate yourself so at the very least you have your facts right.
Even in America chiropractors assume your back pain is due to subluxations, or “alignment” issues with the spine. It is complete crappola. There is no evidence these sub,uxations exist, or that they cause the conditions chiropractors say they do.
Manipulation may relieve pain, but not for the reasons your chiropractor thinks. They certainly have zero training or knowledge on how to deal with real medical issues.
Martin, I appreciate what you and some others are saying in regards to certain chiropractors. I am a chiropractor and have to deal with the small factions who behave as you say.
But let it be known that I am also in chiropractic education and the graduates of the last 10-15 years are educated in the latest in neurological mechanisms regarding manipulation and its effects. There are some who still “believe” in malalignment issues if you will (even more prevalent seems to be that some talk in terms like that because they think patients understand this easier than what we know is really going on from current literature), but most new grads I have trained are well versed in the biomechanical and the neurochemical effects of manipulative procedures that we know to date. Some of the work by Skyba and Dishman have discussed mechanisms of nociceptive inhibition at the motorneuronal pool at the cord level as well as descending inhibition mechanisms.
Further, chiropractors are trained in differential diagnosis and how to recognize more serious pathology and when to refer or co-manage and when to activate proper health care pathways. If a patient comes in with red flags, the chiropractors I know and have trained refer them out for further imaging/consultation.
I know it is easy to paint with a broad brush and I recognize the problems in my own profession. However, know that the profession has largely changed in the US (yes there are still fundamental factions) and we are doing our absolute best to combat the image you describe. It would be awesome if educated folks like you and others on this board would help us.
adam wrote: “…know that the profession has largely changed in the US (yes there are still fundamental factions) and we are doing our absolute best to combat the image you describe. It would be awesome if educated folks like you and others on this board would help us.”
The profession has not “largely changed” in the US, or elsewhere for that matter, including the UK where the requirement to follow evidenced based practice is being flouted by a large percentage of chiropractors:
http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1827-alliance-of-uk-chiropractors-october-2010-newsletter.html
Readers should be made aware of the fact that despite the claims of many chiropractic leaders that ‘modern’ chiropractic has discarded its pseudoscientific roots, there is plenty of evidence to demonstrate that pseudoscientific beliefs remain widespread. The best example is probably to be found on the website of the World Federation of Chiropractic (WFC). The WFC is an association of chiropractic organisations in 85 countries and it has adopted an “identity statement” based on a survey in which thousands of chiropractors were asked how the public should perceive them. [Ref. Carey PF and others. Final report of the Identity Consultation Task Force, April 30, 2005]
The survey report states that 65% of respondents said that the phrase “management of vertebral subluxation and its impact on general health” fits chiropractic “perfectly” or almost perfectly. [Consultation on Identity. Quantitative research findings. (Slide #30) World Federation of Chiropractic, Dec 2004]
Those figures are supported by a 2007 survey of UK chiropractors which revealed that traditional chiropractic beliefs (chiropractic philosophy) were deemed important by 76% of respondents, with 63% considering the subluxation to be central to chiropractic intervention:
http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1188-the-scope-of-chiropractic-practice-a-survey-of-chiropractors-in-the-uk.html
Sadly, Adam, the above doesn’t seem to be indicative of any sort of widespread reform.
How do you know how much or how little training chiropractors have? did you attend chiropractic school and read the textbooks and write the exams? What would you say are “real”medical issues?
“The three deplorable episodes summarised here speak for themselves, I think. I will therefore abstain from further comments and am delighted to leave this task to the readers of this blog.”
I’m more that happy to comply with your request, Dr. Ernst.
(Not my usual source), but here is a collection of YouTube videos about the harm done by Chiropractors when they *practice* medicine, including *manipulations* that cause dissecting carotid/strokes/deaths.
http://www.youtube.com/watch?v=1HuJunzTg50
lilady, USA, BSc.-Nursing, Registered Nurse
As Dara O’briain sad “Those who live in glass houses should masturbate in the basement -” and chiropractors do increasingly live in glass houses!
I go to a chiropractor in Australia regularly and have done for a long time to avoid living in pain in my back and hip. She gives a great massage to relax all muscles and gently manipulates to get bits back in place. When my daughter injured her neck 15 years ago this chiropractor after asking about the cause of the injury, insisted we take her to hospital immediately. A good call as my daughter had torn the ligaments in her neck.
At no time has my chiropractor even hinted that she can cure any medical problem and I have never heard of Australian chiros doing that.
I’m confused, why would an chiropractor with no medical training who basically gives you a massage be better than a trained physio who would be far more capable of informing you of serious issues?
Australian Chiro do claim all sorts of magical things from “immune system” improvement, to collic cures, to treating liver failepure. Even the Chiro you saw does claim something that is woo. There is no realignment of the joints going on. That is completely incorrect. Yes the massage helps, but not for the reason your Chiro thinks.
Even the Chiro that do simple things, still do it based upon a fraudulent premise. If it works, and sometimes it does, it is by accident.
The bits don’t go back into place. They were never out of place. That side of Chiro is as fraudulent as those that say they can treat Collic. The muscles spasm may have been released, and lesions reduced, and maybe even some inflammation and nerve entrapment reduced. However this idea that “re align” things is not just wrong, but stupidly wrong.
Why would anyone ever go to a chiropractor…when we have Registered/Licensed Physical Therapists who provide habilitative and rehabilitative therapies that are prescribed by real doctors such as Physiatrists and Orthopedists?
Here’s an instance of a blind chiropractor in Australia, who didn’t act in his patient’s best interests…
http://luckylosing.com/2012/03/20/blind-chiropractor-who-fiddled-whilst-patient-lay-dying-suspended-for-12-months/
There’s a small paragraph tucked away in an article written by the President of the British Chiropractic Association, Richard Brown, which was published in The Chiropractic Report in November 2011, which seems to sum up the reasons why lessons aren’t being learned – or rather, not being adhered to:
Quote
“Sadly, with the stark realisation that the cake is being sliced ever more thinly, combined with student debt and escalating living costs, it is unsurprising that new (and not-so-new) graduates are seeking innovative ways of making a living. Inevitably, however, innovation for some means sailing closer to the wind than ethics and professionalism permit. Cue one sceptic feeding frenzy and a panoply of Ernst-fuelled editorials.”
http://chiropracticreport.com/portal/images/back_issues/No_%206%20-%20Nov%202011.pdf
This “sailing closer to the wind” seems to be enabled in the UK by the General Chiropractic Council’s chiropractor-friendly definition of evidence based care which apparently does nothing to prevent chiropractic prejudices from flourishing:
http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1791-gcc-guidance-on-the-vertebral-subluxation-complex-2010.html
The General Chiropractic Council also seems content to allow (albeit covertly) mythical chiropractic ‘subluxations’ to be ‘corrected’ under the dubious banner of “health concerns”:
http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1825-subluxations-still-no-evidence.html
As chiropractic’s watershed moment is still clearly a very long way off, a further “panoply of Ernst-fuelled editorials” is, IMO, inevitable and justified.
BTW, how ridiculous of chiropractors to think that the World Federation of Chiropractic can in any way be taken seriously when, similar to the General Chiropractic Council, its own identity statement fails to place proper limitations on chiropractors who use spinal adjustments to treat general health problems. That cannot mean anything other than it is happy to aid in the promotion of bogus treatments (which, as those outside the in-denial chiropractic community are aware, can give rise to life-threatening complications):
http://jmmtonline.com/documents/HomolaV14N2E.pdf (p.4)
Dear Blue Wode,
In regards to your ‘sailing close to the wind point’ it actually states that the GCC does not advocate the use of the term ‘subluxation’. This is because it is a theoretical model that cannot be medically verified. I would say that medicine has problems verifying many concepts. In musculoskeletal terms medicine fixes very few things in my experience. It may ease pain but the underlying cause is always there still. It will come back at a later date with greater ramifications
It’s easy for critics to say that “all chiro’s do this and that” but that isn’t true. I’ve never read any work of the Palmers and do not use the term subluxation when talking to my patients. My treatment plans are evidence based, which cannot the said of GP’s who will dish out NSAIDs like sweets due to their lack of real knowledge on musculoskeletal issues. NSAID’s kill 2,500 people a year in the UK, i’ve been treating people daily for 8 years and have never had an adverse reaction. The argument that chiropractic manipulation cause strokes is based on poor cherry picked evidence from people like Edzard Ernst. Asking people to fill in questionnaires hardly constitutes high quality methodology wouldn’t you agree?
Time for some people to wake up and stop letting their bias get in the way of their opinions about a topic that they know nothing of.
Any adverse reaction reported from manipulation will rarely be from a skilled chiropractor. Many people learn to do joint manipulation after they have studied other courses. Chiro’s are learning about adjustments from day one a 5 year course.
I learnt to do dry needling over 4 days but that doesn’t make me a skilled acupuncturist does it.
I fear that chiros learn a lot of nonsense during their education – and even the most rigorous teaching of nonsense will result in nonsense.
Chris W wrote: “In regards to your ‘sailing close to the wind point’ it actually states that the GCC does not advocate the use of the term ‘subluxation’.”
Nevertheless, the *vitalistic* Alliance of UK Chiropractors pressured the GCC into changing its mind about there being no evidence to link imaginary chiropractic subluxations to “health concerns”. Where’s the evidence to support the GCC’s U-turn? See:
http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1827-alliance-of-uk-chiropractors-october-2010-newsletter.html
Chris W wrote: “It’s easy for critics to say that “all chiro’s do this and that” but that isn’t true. I’ve never read any work of the Palmers and do not use the term subluxation when talking to my patients. My treatment plans are evidence based, which cannot the said of GP’s who will dish out NSAIDs like sweets due to their lack of real knowledge on musculoskeletal issues. NSAID’s kill 2,500 people a year in the UK.”
A poor argument. Your personal anecdotes are irrelevant. As for NSAIDs, for a true comparison with chiropractic spinal manipulation one would have to take into account the list of factors itemised at the end of the first section in this link:
http://www.chirobase.org/18CND/03/03-03.html
Chris W wrote: “i’ve been treating people daily for 8 years and have never had an adverse reaction.”
You don’t know that. Strokes resulting from chiropractic treatment can be delayed by up to 30 days or so, and my not be attributed to being caused by, or exacerbated by, chiropractic manipulations when they are known to have occured (especially in an elderly population).
Chris W wrote: “The argument that chiropractic manipulation cause strokes is based on poor cherry picked evidence from people like Edzard Ernst.”
Wishful thinking. Edzard Ernst is robustly scientific in his methods, and, in the interests of patient safety, follows the precautionary principle (unlike most chiropractors who have no reliable screening methods for their neck manipulation treatments, yet use them much of the time despite their carrying a risk so catastrophic that any responsible risk/benefit assessment would invariably contraindicate such an intervention).
Dear Blue Wode,
It’s nice to see my personal anecdotes brushed off as irrelevant.
Nice put down that. People’s experiences are irrelevant? Hmmm ok. As for adverse reactions i live in avery small town and i would know of any adverse reaction very rapidly. It’s because of this network that i have seen over 1,000 people in my short time here without any marketing. It’s just word of mouth.
As regarding NDAID’s there are 2,500 deaths. It’s irrelevant what the risk factors are. How can you support system that creates so much suffering?
Furthermore, from my reading Edzard’s research techniques are hardly ‘robustly scientific.
You mention the Welsh Institutes curriculum being intellectually challenging. Does that mean you studied there?
Chris W. wrote: “It’s nice to see my personal anecdotes brushed off as irrelevant. Nice put down that.”
Not a put down, as you should be aware, anecdotes are not scientific evidence.
Chris W. wrote: “As for adverse reactions i live in avery small town and i would know of any adverse reaction very rapidly.”
You don’t know that for sure. The absence of grapevine news is not scientific evidence.
Chris W. wrote: “It’s because of this network that i have seen over 1,000 people in my short time here without any marketing. It’s just word of mouth”.
It’s word-of-mouth marketing, and has nothing to do with science.
Chris W. wrote: “As regarding NDAID’s [sic] there are 2,500 deaths. It’s irrelevant what the risk factors are. How can you support system that creates so much suffering?”
NSAIDs work (so have a favourable risk/benefit ratio); they are used by a vastly greater population; they carry Patient Information Leaflets (which patients may choose not follow, and thus experience adverse events); and they are subject to post-marketing surveillance. By comparison, chiropractic may not work beyond non-specific effects, is used by a tiny percentage of the population, fails greatly when it comes to informed consent procedures, and doesn’t have any reliable adverse events monitoring in place.
Chris W. wrote: “Furthermore, from my reading Edzard’s research techniques are hardly ‘robustly scientific’.”
Please cite examples.
Chris W. wrote: “You mention the Welsh Institutes curriculum being intellectually challenging. Does that mean you studied there?”
No.
Interesting development.
http://www.ncbi.nlm.nih.gov/pubmed/22483611
@ fedup
Yes, interesting, but note the words “…does not appear to place undue strain on VA…does not seem to be a factor in vertebrobasilar injuries”. Until more is known, the precautionary principle still applies, i.e. the risks of cervical SMT continue to outweigh any perceived benefits. Furthermore, even if cervical SMT was ultimately proven to be safe, there are still other harms from chiropractic treatment to consider including decreased use of immunisation due to misinformation given to parents, psychological harm related to unnecessary treatment, psychological harm caused by exposure to false chiropractic beliefs about ‘subluxations’, and financial harm due to unnecessary treatment.
It’s also well worth noting that vertebrobasilar injuries aren’t the only ones associated with chiropractic treatment. As there are no reliable screening methods available to chiropractors, it’s hardly surprising to see in the recent medical literature a report of cerebral embolus following chiropractic manipulation in a patient with a calcified carotid artery:
http://www.ncbi.nlm.nih.gov/pubmed/22818061
Here are two more examples of non-vertebrobasilar chiropractic injuries reported in the recent medical literature:
Partial pancreatic transection due to chiropractic manipulation
http://www.ncbi.nlm.nih.gov:80/pubmed/22964174
Posterior rib fractures in a young infant who received chiropractic care
http://www.ncbi.nlm.nih.gov:80/pubmed/23027167
In addition to the above, there are likely to be many injuries caused by chiropractic treatment which are never reported, not least because chiropractors have no reliable adverse event reporting systems in place, and don’t seem to view establishing any as a priority. It’s interesting to note that the General Chiropractic Council recently commissioned (and subsequently dropped) a draft document on revalidation, the purpose of which was to provide an analysis of the risks and benefits of chiropractic with the aim of establishing if there was a business case for revalidation. In section 5.72 of the document, the British Chiropractic Association admitted that its members had *caused* patient rib fracture injuries, and in sections 5.13 (along with the McTimoney Chiropractic Association), and 5.64, the Scottish Chiropractic Association apparently ignored the request for details of patient incidents and complaints. See here:
http://www.gcc-uk.org/files/page_file/C-170210-04a.pdf
So, in essence, things still aren’t looking good for chiropractors with regard to treatment risks.
Thank you BW; this explains very clearly why chiropractors will find it hard or even impossible to free themselves from their long tradition of quackery.
Dear Edzard,
When i left the AECC i was termed a ‘safe and competent’ practitioner. It is through hard work that i have gained a modicum of expertise in my field. I always read your comments with great interest, however you are using an age old argument that is obsolete. Contrary to popular belief people who train to be chiropractors are also free thinking individuals. Your comments would indicate that there is a chiropractic dogma that is always adhered to by chiropractors. This is obviously not correct. I have never used the term subluxation with any of my patients. The pain based model of medicine is inappropriate and obsolete when it comes to treating many musculoskeletal conditions. That is fact.
I am not a quack. My treatment is based on sound evidence based research. Current NHS protocol on treating LBP (2009) includes the option to refer a patient for 9 session of manipulation over 12 weeks. Manipulation is not chiropractic however. This is akin to saying all dentists do is pull teeth. Your opinions are flawed as you have no experience of a day in day out job of helping people who are woefully looked after by medical procedures. I have saved many people from iatrogenic disability simply by getting certain joints moving properly, getting them to engage in a simple rehab routine, and usually to engage in some exercise to help them lose weight. It’s not rocket science. I’ll quite happily take the ‘Pepsi Challenge’ on anatomy and neuroanatomy, or any musculoskeletal issue with any GP. Incidentally, i gained a Sports Sience Degree and an MSc in Exercise and Nutrition Science years before i trained to be a chiropractor. There were 14 physios who were retraining to be a chiropractor in my year alone. A chiropractor is a skilled differential diagnostician, a radiographer, and a highly skilled physical therapist. It’s a one stop shop; a high street specialist like a dentist or optometrist. Again, this isn’t rocket science.
You should take up people’s invites to observe work in their clinics, or go to the AECC or the Welsh Institute of Chiropractic. The 5 year course that we all take is extremely academically and intellectually challenging. Unless you have been through these course and practiced for many years you do not have the authority to make the conclusions you make because you do not truly understand chiropractic.
Manipulation is not chiropractic but you seem to hold onto this belief to defend your standpoint. It’s an easy angle for you because you are using the old line of chiropractic dogma instead of addressing the modern day perspective that many biomechanically based chiropractors adhere to.
Regards
Chris W
Chris W wrote to Edzard Ernst: “Your comments would indicate that there is a chiropractic dogma that is always adhered to by chiropractors. This is obviously not correct.”
It’s true that chiropractic dogma is not *always* adhered to, but evidently it is adhered to by the majority of chiropractors, including many here in the UK. For example, here’s the mission statement of the Alliance of UK Chiropractors:
Quote
“Our vision is to create a vitalistic, Chiropractic model of health and well-being for families in the UK by providing the distinct elements offered by Chiropractic as a healthcare profession predicated upon its philosophy, science and art.”
http://www.facebook.com/pages/Alliance-of-UK-Chiropractors/151897244826008?sk=info
Chris W wrote to Edzard Ernst: “You should take up people’s invites to observe work in their clinics, or go to the AECC or the Welsh Institute of Chiropractic. The 5 year course that we all take is extremely academically and intellectually challenging.”
Indeed. FYI, one academic found the Welsh Institute of Chiropractic’s degree programme extremelly intellectually challenging:
http://sciencedigestive.blogspot.co.uk/2010/06/email-to-university-of-glamorgan.html
How do you know most UK chiropractors adhere to? As i’ve said before most chiropractors are free thinking highly educated individuals. The ‘Mission Statement’ of the Alliance of Chiropractors talks about a ‘vision to create a vitalistic’ model. I do not follow a vitalistic model, i know many who don’t. My education has been based in science. MSc, BSc, MChiro, Physics and Chemistry A levels amongst others.
As for offers to attend clinics or courses. Why are no offers accepted?
Definition of quack from the Oxford Dictionary
noun
“a person who dishonestly claims to have special knowledge and skill in some field, typically medicine”:
It would appear “quacks” are people who pretend to have expertise in subjects they know little about, presumably subjects like, chiropractic medicine or acupuncture. I practice chiropractic, I dont diagnose or treat illness or disease, I dont make medical claims. You may not like chiropractic or understand it, however practicing chiropractic would not appear to conform to the definition of “quackery”, however claiming to have “special knowledge” about chiropractic and having only been trained as a medical practitioner may in fact make you a “quack” professor Ernst. All I do is maintain movement in spinal joints that become stiff from sedentary lifestyles, movement effects function of mechano receptors(nerves) in spinal joints. You may not believe that is possible, you may not believe maintaining joint function is important or that it effects wellbeing, you are perfectly entitled to your opinion, however I am not so confident of you depth and breath knowledge in anatomy and physiology. You might start by asking, why joints were immobility post surgery in the 80s and now post surgical treatment is all about maintaining joint motion as chiropractors have been advocating for years.
You will find dirt by scraping the bottom of any barrel, you are welcome to visit my practice and quiz my clients any time you like, you may even check my cellar for “victims” of spinal manipulation.
Richard says he does not make medical claims! I think he has not recently looked at his own website. I am truly getting tired with quacks who tell lies without even blushing.
I live in the Isle of man, UK ,2003 woke with asleep neck NOTHING MORE due to a lack knowledge and wanting to play in a important Football game 10 days away i sort some anti inflammatory from a GP how said a Chiropractor would do the job in one vist ,So know nothing but trusting in 2003 that they must be OK as my doctor set me , the was only one .What happened next has ruined my life , i lost everything . Mr R langian knows a MR C . Walker who now works as a chiropractor on the IOM .
The gent i seen was not a qualified chiropractor and in the space of 5 min of entering the room he had started manipulating my neck , by the 4 ( four ) time i was in a mess a asked to stop made it home only to end up in trauma unit with two ruptured discs ( never got the feeling back in my left arm i lost ) and a third discs on the verge . The pain was so bad i was moved to a special room , 4 days went by in no 15 min spell did any nurse register me a sleep . The shock to my body nearly killed me . I left hospital 2 weeks later and spent 3 month crawling the walls with pain. 1200 mg Codeine phosphate and 500 mg of tramadol did not touch it ( yes am very well aware those mg are way above the limits ,240 mgCP it for an adult )
I took him to court and won , Mr wright head of muscular skeleton at london hospital plus two other all agreed he was the cause . What did i get nothing what happened to him ,nothing . Right there is a huge problem for chiropractors there are good and bad , i think as many bad as good and should come under proper government control but when they get it wrong the effect are life changing .
I did look in too a lot of facts and one stuck with me and was part of the court case ,you have 1/100,000 chance regardless of a rupture under manipulation something you don’t tell the client , in Canada around that same time 3 people died in the chair . I don’t know the truth i just wish that the fact were more clear and the punishment if you do mess up be huge .
I wont lie i harbour no love for chiropractor ,but still think it’s a matter of the person and may be not the art .
Sorry to hear about your horrible experience Mr Stewart, I dont know the chiropractor personally, but on the GCC register it states he only graduated in September 2005, as you point out there is a high level of skill involved in a chiropractic adjustment and I would be reluctant having a new grad adjusting/manipulating my neck. I suppose they have to get experience somewhere. In medicine they call this period “the killing season”, death rates in hospitals increase by 8% when the new grads come out http://www.dailymail.co.uk/news/article-2163382/NHS-wards-Patients-risk-junior-doctors-start-new-jobs-says-health-boss-Sir-Bruce-Keogh.html. If you are ever in Kingston look me up, hopefully my hands will have recovered from the effects of chemotherapy by then and I may be able to help you. No one warned me about the possibility of peripheral neuropathy from chemotherapy and I was pretty pissed off to be told there was nothing the doctors could do to help me. I thought my cancer nightmare would finish in April, turned out that April was the beginning of the nightmare, could not walk 50m even button my shirt or tie my laces, never mind play tennis or work. However I am getting there slowly, thinking outside the box and doing things no doubt Edzard and BW do not approve of, not being bothered about published “evidence” helped me. I chose to rely on the experience of the practitioner, I was happy to try anything, I just wanted to feel better and I am slowly getting there and you can too. The body has remarkable ability to repair itself, sometimes it needs a little help. As I outlined in above comment.
It looks like, in chiro-colleges, they do not teach that the plural of anecdote is anecdots, not evidence.
I may not be able to spell it, but I do understand EBM, in fact I hoped Simon Singh would have lent you David Sacketts book on Evidence Based Medicine, I gave him a present of earlier in the year, because I could see from your book Trick and Treatment neither of you had read it. Your definition of “evidence” focused exclusively on “published evidence” which represents only one of Sacketts three pillars of evidence (not very scholarly). I can only conclude you have a very limited understanding of evidence based practice. This article may help; http://www.hsl.unc.edu/services/tutorials/ebm/whatis.htm. You would be amazed at the interest in the methods I used to cope with cancer treatment. Doctors want to know how you get people who are exhausted from chemo to exercise and over come their fears. There are ways, you wont find the answers in a data base, you will find them in the practices of clinicians with good people skills. Again I invite you to come and observe my work and let me explain the anatomy and physiology behind what i do.
looking at your website, one might doubt that you have the slightest clue about EBM. yet I am happy to hear that you read a decent book.
**** please read ******I wrote sometime back about a incident in the Isle of man were I was injured .Unfortunately it reads like a Mr Chris Walker chiropractor at Back2 life clinc was the chiropractor , HE WAS NOT ! Chris walker is a well respected member of the community and we’ll know for will a good reputation .Chris Walker only actions have been to help if asked .Regualess of opinion he himself conducts his practice safely and has never harmed a single person .If possible I would like my statement removed as to not cause any misinterpretation of Chris Walker chiropractic clinic .
I’d like to inform the ill informed as to the depth of chiropractic education. Please do not misconstrue a master of chiropractic degree for a mean feat. You may visit the WHO guidelines on chiropractic education to see the breakdown in academic requirement, or even invite me, a chiropractor, to take part in any human anatomy, physiology, general diagnosis, pathology, neurology, orthopaedics, biomechanics, clinical examination… Again. I assure you, we study from the same textbooks and sciences that medical doctors study from. I spent a good part of 4 years in Cardiff university hospital studying in the same room as medical students, pharmacists. I know my stuff. We all did.
Chiropractic is first and foremost a primary contact health care profession. We treat people. Not illness or disease or back pain or migraines. We treat people, not symptoms. Once you understand the difference between fighting fires and preventing fires, you realise the beauty of chiropractic. It’s as safe as any public sector health care profession that deals with people with health challenges. When we talk about chiropractic treatment we are in essence talking about proprioception. Proprioception is our Global Positioning System. Our ability to navigate through our environment through movement. When joints don’t move, they dont produce proprioception afferents. Your body can’t function without propriocepive afferents! Try walking on a leg that’s paralysed. No? What about peripheral neuropathy? Do you know why they are at risk? Because there’s no propriocepive afferents. So when your L5 doesn’t move (for reasons I can explain but you’ll have to invite me over for tea) how are your para spinal muscles supposed to stabilise your spine? How are you supposed to maintain muscle tone when your spinal cord is missing sensory information from the most abundant receptor in your body – the muscle spindle? Are joints bones? Muscles? Ligaments? Nerves? Mechanoreceptors? Cartilage? Vascular? They’re all of this stuff! Come on!! Have you never heard of Panjabi’s model of spinal stability? Have you never heard of Kirkaldy-Willis model of spinal degeneration? Janda and Levit? Bogduk? The bio mechanical model? Stuart McGill? Craig Liebenson?? Cervicogenic headaches through trigeminocervical nuclei? Gordon Waddell’s back pain revolution? How can you ignore all this wonderful stuff and listen to waffle about quackery? You know I’m currently working on my PhD in joint biomechanics, and one of the major predisposing factors for patella-femoral pain syndrome is (and I quote) joint malalignment.
And why do chiropractors see non-musculoskeletal changes in their patients? Because its all connected! Did you know your gastrocnemius drives adrenal function? Did you know that muscle strength is a predisposing factor for death? (Ruiz et al. BMJ 2008) Do you know how myotatic reflexes work? Withdrawal reflex? Stretch reflex? Muscle tone? Your cerebellum function in regulating posture and unconscious movement? Did you know that 90% of movement is non-voluntary? Did you know that your heart is not the only muscle that pumps blood through your body, but just about every gross movement muscles facilitates bloodn circulation? Not to mention the smooth muscle in your arterial media. Sympathetic nervous system function? Regulation of homeostasis? 80% of your nervous system is in your digestive system?
Please just for once, ask us questions instead of pointing fingers. Believe it or not we are here to HELP people!
again: the teaching of nonsense will result in nonsense
Take up the offers to attend chiropractic clinics and the educational establishments.
What are you afraid of Edzard?
very amusing to see that you seem to think that I have no experience in spinal manipulation/chiro clinics.
Edzard in the light of your above response, I will ask one “quack” to another, in the knowledge you are unlikely to answer the question? Do you think its “medicine” to say “exercise” or nutrition can have a beneficial effect on organ function. What I describe on my website is chiropractic not medicine, as I have experienced it. My experience not yours, you have no experience of practicing chiropractic. Your knowledge is limited to reviewing chiropractic research. You say its not impressive, I don’t disagree, with you its not, chiropractic researchers need to do a lot better and I don’t say or imply otherwise on my website. Presumably below are sections you are referring to.
“There are many ANECTOTAL reports of all sorts of conditions benefiting from chiropractic care. I see these positive responses every day in practice. Skeptics would call these effects PLACEBO, I explain these responses as the effect spinal joint dysfunction can have on organ function and the “autonomic nervous system” (ANS). The vast majority of patients who present at Spinal Joint have MUSCULOSKELETAL conditions. In 2008 we did an analysis of all the conditions patents had presented with. Some patients might have 2 or three different complaints and I Would SAY, the vast majority of them benefited from chiropractic care.
Then if you follow the link there is a breakdown of what “medical conditions” people presented with and the following statement “We are not stating that spinal care CURES these conditions however for a variety of reasons we find improving spinal joint function does improve the QUALITY of life of the vast majority of our clients. If you click the links there is PLAUSABLE evidence and CASE STUDIES of people being HELPED, by spinal care” My website is at http://www.spinaljoint.co.uk and I am sure if the ASA had a problem I would have heard about it a long time ago.
I would be happy to participate in any study you care to do as long as I can choose the chiropractors that would participate. Your assumption (your methodology) that you can go out and randomly choose 100 chiropractors to perform “spinal manipulation” for a study is laughable. It is like saying you could examine any 100 golfers to figure out the best method to win a major. Its that experience that can make the difference to clinical outcomes and no doubt why Sackett attached such importance to it. You say EBM is a “good” book, so why then did you ignore experience and patients values when defining “Evidence Based Medicine” in your book, why did you leave out the two other pillars from your definition. After all you understand it so much better than me, or so you say.
Jesgol wrote: “ I’d like to inform the ill informed as to the depth of chiropractic education. Please do not misconstrue a master of chiropractic degree for a mean feat. You may visit the WHO guidelines on chiropractic education…”
You may also visit the WHO’s 2003 bulletin on Lower Back Pain (the most common complaint treated by chiropractors)…
Quote
“People with low back pain often turn to medical consultations and drug therapies, but they also use a variety of alternative approaches. Regardless of the treatment, most cases of acute back pain improve. At the time, people in such cases may credit the improvement to the interventions some of which clearly are more popular and even seemingly more effective than others (e.g. chiropractic and other manipulative treatments in which the laying on of hands and the person-to-person interaction during the treatment may account for some of the salutary results).”
Quote
“The spread of chiropractic and other manipulative treatments worldwide has won many adherents to this treatment , who perceive that it works better than others. This hypothesis was recently put to the test (25) and, although the respondents still favoured such approaches (chiropractic adjustment, osteopathic manipulation, and physical therapy) perhaps because of the time spent and the laying on of hands meta-analysis cannot confirm the superiority of manipulative treatments (or, for that matter, of acupuncture and massage (26)) over other forms of therapy, or even time as a healer (25), which substantiates the contentions of WHO’s document (1). In most instances, manipulative treatments are more expensive than others (apart from surgery) and not more helpful to outcome (26).”
Some more interesting comment on the WHO and chiropractic…
http://skepticbarista.wordpress.com/2010/10/24/subluxations-who-said-what/
Mr Stewart my sincere condolences for your tragic experience. It saddens me to hear of anyone who has suffered at the hands of a chiropractor. The bottom line is, you do not just adjust everyone. It is humbling to read in your last sentence that it is not the art, but the artist in some cases that is at fault. This rings true and true the more I read about cases where patients have had significant adverse effects of spinal manipulation.
I am finding more and more patients in my clinic who, at first consultation, are not candidates for spinal manipulation. Firstly, I do not believe that the underlying cause of their complaint is musculoskeletal, and secondly I do not believe their body is strong enough to handle changes in proprioception. These patients require the utmost delicacy when being managed and often times, spinal manipulation can only be tolerated once the underlying problem has been resolved. In this instance, once I have demonstrated the safety and necessity of spinal manipulation will I then proceed. Alas, even this amount of care and consideration would not prevent exceptionally rare adverse outcomes such as vertebral-basilar dissection – something I would deem unavoidable without Angiographic screenings (the logistics of which would prove impossible).
In your specific case, I would say that there was an underlying issue regarding your neck – perhaps the reason you consulted this practitioner in the first place. In which case his treatment was beyond the limits to which your neck could withstand, and the resulting injury ensued. Unfortunately, the biggest injury has been to your trust in the chiropractic profession, who I believe could resolve the reason you consulted him in the first place. If you would be interested in hearing what I have to say on the matter I would be more than happy to give you some of my time to direct you towards finding the solution. Naturally the risk of such an encounter would be negligible as, I’m sure even Prof. Ernst would agree, the risk of chiropractic consultations over Skype is deemed safe. Although there is no peer reviewed evidence to suggest this…
Are all chiropractic consultations entirely safe? Sorry Jesgol, but the answer is NO! we have repeatedly shown that chiro- advice can be a risk factor to your health, e.g. http://www.ncbi.nlm.nih.gov/pubmed/12228144, or http://www.ncbi.nlm.nih.gov/pubmed?term=schmidt%20k%20ernst%20e%20respiratory%20medicine
Chiro advice a risk to your health? You are using an exception to prove your rule Edzard (by the way that message by Jesgol wasn’t in bold when he first put it up there, you’ve done this).
The most dangerous discipline in the world is medicine bar none. NSAIDs alone can be attributed to 2,500 UK deaths per year and bad advice by GP’s and MD’s causes more disability than you would think. When i mean disability i mean not being able to work, to provide for the family due to bad advice from medical people who do not usually see the ramifications of their bad advice.
Chiroporactic advice is very good for your health. The ‘chiropractor’ who caused Mr Stewarts problem was not fully trained and was not GCC registered so he was NOT a chiropractor. He was a manipulative therapist. Your research used manipulations by manipulative therapists but you infer that this means chiropractors.
The BCA countered you with research involoving 50,000 chiropractic manipulations with any adverse reactions.
It appears you are perpetuating an urban myth?
Chris W. wrote to Edzard Ernst: “That message by Jesgol wasn’t in bold when he first put it up there, you’ve done this”
That was my fault for not checking my bold tags prior to posting.
Chris W. wrote to Edzard Ernst: “The BCA countered you with research involoving 50,000 chiropractic manipulations with any adverse reactions. It appears you are perpetuating an urban myth?”
Here’s something about that Bolton and Theil study cited by the BCA that may have escaped your notice:
http://www.ukskeptics.com/forum/showthread.php/1610-Value-of-chiropractors-questioned?p=32759&viewfull=1#post32759
Dear Jesgol and Mr Ernst
First ,am dyslexic ,so sorry for the poor writing skills ,its by no mean a reflection of my intellect
Two thing i would like to say one ,first and foremost ,the pond life that treated me was not a chiropractor ,but a man who had left his course early . This was brought to my attention by another chiropractor,i wont name him as i have not asked him can i ,but he was very disappointed and i know of his work since . I ask myself if i could would even knowing now what i do would i have gone to the gent in mind , my answer is yes , please Mr E Ernst don’t take this as me saying your wrong ,am not am saying that , i have spent 8 year in pain .i have lost everything many times the idea i may not wake up would be a comfort ,on both side it the one thing a cant convey enough ,real chronic pain back pain is like cancer but you die slowly . But what i have witnessed on the other hand in the 8 years is a mass of pass the buck ,don’t have a clue,have as much morphine as you like ,you tried physio that never worked so that out the window ,15 ,yes 15 consultants later no answer to why my lower back developed this chronic pain after all i hurt my neck not my lower back . Yes i can put together an argument based on biomechanics .
One Consultant said this ” why don’t you go home and lift the heaviest thing you can and then they will rupture and they will have to do something ” words for word . not an embellishment .
All so been to England best nhs hospital for pain treatment and this leads to my second point about med report and the evidence they throw up i now believe to me a mixture of truth and the messed up minds of those who suffer for a period of time . Do people lie about back pain yes !! do they play on it yes ,does stress have a big part and depression ,yes .
Does it make you angry ,very . If you have met as many as i have then you will know it would be very hard to get non surgical back pain problem put in to a set of data and come out with any facts .
In the last 8 years i have had the joy of serotonin syndrome 4 time due to doctors messing up ,the list of mistake like traction to my neck that made DR piggott at Walton Nero flip could gone on and on if this was all about chiropractors then it would be damming but it not it how the NHS deal with it ,as i type this i can feel my eyes watering up 2003 Aug 19th was Avery bad day for me . have the day since been worse yes much . The way the NHS deal with it is no better as they them self have no answer . So i think if a group studies the back learns as much as they can listen to there patients and come up with ways to fix the back be it in there mind or not compared to along draw put liver killing life draining ,CBT , conservative approach
I would say to you Mr Ernst would be doing me a huge favour and go and see if what they say stand up . I don’t know anyone with a back who screwed like me that goes to see a chiropractor i know 100s that to the NHS . I know of friend who say it worked ,men with sciatica unable to walk back at work the next day etc etc .
In summary , i have no love for chiropractors what so ever ,more so than you Mr Ernst . I will ask you this who many people do you think the conventional way kills and is the other option entiley safe ?? , i lost friends because the blank wall drove them to killing themselves. You don’t help me or other if you wont engage in open full heart debate . I think it is the person and may not the art , just scared that may get away with being bad artist .
PS I have seen the dismissal of acupuncture in the second blog up , this i find distressing as it just makes for more confustion . i have seen a bowel operation done using just needles as an pain block ,how would anyone say that not some king of proof
Dear Edzard/Blue Wode,
whilst I don’t disagree that there is no RCT evidence available in support of some of some the claims made historically by some chiropractors and associations, I do not agree that there is no evidence available in support of chiropractors. Whilst I agree that there might be risks associated to the treatment provided by chiropractors I disagree that the non-declaration of those potential risks is endemic to the profession. Whilst I agree that it is sad and intolerable for those who have suffered injury to manipulative care I think it equally sad when that happens to those who have received other forms of care and that it is a wrong to vilify a profession for the few errors that occur as no profession will ever be free from error for as long as it has a human element.
Whilst you may think there are no benefits to chiropractic care my patients and those of a profession which has pretty much grown on word of mouth alone over the last century would beg to differ.
Whilst I agree that we are all some times prone to delusion and self-serving rhetoric I would beg your consideration that it may this time be you who is mistaken in some of your assertions, and more over the way you translate them in the public and social media.
Sincerely,
Stefaan Vossen
Stefaan Vossen wrote: “Whilst I agree that there might be risks associated to the treatment provided by chiropractors I disagree that the non-declaration of those potential risks is endemic to the profession.”
More chiropractic wishful thinking. Read and digest this:
http://www.ebm-first.com/component/search/?searchword=informed+consent&ordering=newest&searchphrase=all&limit=0
BTW, Stefaan, are you and Richard Lanigan still de-registered UK chiropractors? If so, would you like to explain to readers why.
Hi BW, how does a comment thread about people having strokes comment about consent? Do people who give consent not get strokes? I fail to see the validity of your response.
For an outline on my de-registration please go to http://www.chiropracticlive.com/dear-margaret/
Chris: try to read what has been written and stop getting apoplectic. I asked ” are all chiropractic consultations entirely safe?” and showed that the answer is NO. Who is using exceptions and for what???
And i did not change the print – i don’t even know how to do this.
Dear Edzard,
I think you will agree that no process or procedure is entirely safe (please correct me). Therefore your question to Chris is fallacious and the answer misleading in its potential conclusion.
Stefaan
Entirely safe? Advice by chiros? We have looked at this systematically http://www.ncbi.nlm.nih.gov/pubmed/20389316 and found that the vast majority (very close to 100%) of claims by chiros or chiro-organisations is unsafe. And claims constitute advice, the way I see it. So please, be a little more realistic about what your fellow chiros do and do not do.
That doesn’t answer the point I make Edzard nor do I make any statement on chiropractor’s activities, I merely commented on the nature of your question to Chris and as stated the conclusion which could be drawn from it. Do you disagree with the comment that “no claim/advice is free of risk”?
Firstly, it does matter! Secondly, the risk of dangerous advice lies in the frequency by which it is given. My point is that chiro-advice seems, according to the research I and others have done, regularly risky.
I didn’t say it doesn’t matter Edzard, because I agree that it does matter to keep the public safe, I just said that it doesn’t answer the point I made/the question I posed.
Just to pick up on the point you made “the risk lies with the frequency with which (dangerous advice) is given”. I entirely agree as a statement but I question the foundations on which you apply it to chiropractic care. Would you care to elaborate?
I claim to treat low, mid and upper back pain, neck pain and headache, arm and leg pain, and sports injuries.
I do not claim to treat visceral ailments although i have cured many people of them. What seems to be especially responsive is nocturnal enuresis. I had many disagreements with people at the AECC about advertising the treatment of conditions that may not have strong reproducible evidence to support chiropractics effectiveness. I stated that this made the profession vulnerable although this does not mean that chiropractic doesn’t work for such visceral problems.
I feel this made chiropractic an easy target for you and Simon Singh.
http://www.ncbi.nlm.nih.gov/pubmed/22483611 Maybe you are wrong Prof,
Stefaan: where did you learn to build such nice straw-men?
I think you will find that your response is a straw-man. Gnaute se auton
Apologies for the problem with the bold text – it was due to an unclosed HTML bold tag in an earlier comment, which has now been corrected.
– Webmaster
Stephaan: would I care to elaborate? No!
I try to never elaborate on the obvious
Attention all Magic Underwear Gnomes:
If you call yourself a “Magic Underwear Gnome” then people will accuse you of being a Magic Underwear Gnome. If you’re not actually a Magic Underwear Gnome, then the only way to avoid being classified along with Magic Underwear Gnomes, is to remove “Magic Underwear Gnome” from your title, profession, biz name, billboard, mid-day TV ad, etc.. Otherwise, Magic Underwear Gnome is what you are; make peace with it.
Translation:
If the entire basis for the invention of the term you use as a professional title is nonsense (“Chiropractic”), then you are openly classifying yourself as a “Nonsense Professional” deserving of any and all critique of said nonsense.
or…
If you don’t actually believe in or use any unproven concept or technique, then stop calling yourself a Chiropractor. You don’t get to redefine a word to suit the reality you wish to paint for yourself. Own your woo or recant it and never turn back; you can’t have it both ways.
Interesting comment Skeptek but why did medicine get to redefine itself over time? It got rid of a lot of woo, it got better and more refined at what it does, increased its efficiency and reduced its risks… and on that note “medicine” is not ‘just’ a collective name for “all that has been proven to work”, it is the collective product of a paradigm. Chiropractic is as a profession (rightly or wrongly & in my opinion) not yet ready to move in with that paradigm (in my opinion) and I think that many of the objections raised either side of this debate are due to a lack of understanding of each other’s position and traditions.
Stefaan
Skeptek: great comment; it made me laugh. What is more, there is so much truth in it.
My experience with back, neck, shoulder aches span over two decades which were eventually eliminated by a chiropractor.
I had been to the GP, the specialist, several physiotherapists to no avail, resigning myself to lifelong misery. Then I discovered chiros and after a course of treatments, I am now in the middle of the third decade completely pain free and forever grateful to the chiropractic profession.
Of course there are risks to everything including crossing the street.
The treatments given on the NHS do not necessarily guarantee freedom from pain or risk either as has been my experience for over 20 years that I simply stopped going to the doctors to get even more pain killers. When I last looked into the complications of surgery to my back, there were 10 pages of risks on the NHS site including paralysis and the serious risks were calculated to be 1 in 100 with no guaranteed positive results.
1 in 2 people in UK will have back ache sometime in their lives and the NHS is increasingly getting incompetent to cope with the load. The chiropractors have to study four years of intensive medical subjects and go through vigorous training and in my experience are extremely effective and a welcome addition to the medical repertoire available to public.
Martin wrote: “…in my experience…”
Unfortunately, that counts for very little.
lol, not for you maybe but for Martin?#
“I am now in the middle of the third decade completely pain free”
Means nothing. lol just shows how often Blue wode actually meets people let alone has to care or look after anyone.
I think patient experience is the only thing that matters. After all it is the patient who is the primary concern and not what your “randomised controlled trials” say. I think you have forgotten that. Results are everything. When you’ve got a 50 year old on your table writhing in pain because he was unable to stabilise his spine resulting in repetitive micro trauma from a trivial movement, do you think he cares about RCTs? You need the result! We give the result and we keep those patients off the operating table and back to enjoying life.
I’m quite sure that if I was as dangerous as you say and inefficacious in producing results, I wouldn’t have much of a practice and enormous legal bills. But I have a thriving practice and €250 a year indemnity insurance.
..and patient experience is exactly what a clinical trial can evaluate in a way that minimises bias!
As a side note, “randomised controlled trial” was not meant to belittle my respect for scientific method or evidence based practice. It’s simply to emphasise that there’s nothing “randomised” or “controlled” about the method used to study the efficacy of chiropractic treatment. This is because every patient presents with an entirely unique situation. I do not do the same treatment on every patient. It is bespoke to my examination findings and the needs of the individual. I believe that is called patient centred care and falls under the purview of evidence based medicine.
I don’t think you understand the methodology of an RCT – it can easily incorporate individualisation of the treatment. We can randomise 200 patients into 100 who get your best individualised approach and 100 who receive a control intervention. I know this sounds terribly arrogant but, after doing this since ~20 years, I get tired of discussing methodology with people you do not understand it.
http://www.ncbi.nlm.nih.gov/pubmed/22483611
Spinal manipulative therapy (SMT) has been recognized as an effective treatment modality for many back, neck and musculoskeletal problems. One of the major issues of the use of SMT is its safety, especially with regards to neck manipulation and the risk of stroke. The vast majority of these accidents involve the vertebro-basilar system, specifically the vertebral artery (VA) between C2/C1. However, the mechanics of this region of the VA during SMT are unexplored. Here, we present first ever data on the mechanics of this region during cervical SMT performed by clinicians. VA strains obtained during SMT are significantly smaller than those obtained during diagnostic and range of motion testing, and are much smaller than failure strains. We conclude from this work that cervical SMT performed by trained clinicians does not appear to place undue strain on VA, and thus does not seem to be a factor in vertebro-basilar injuries.
Of course, scientific data can be interpreted in many
ways. However, the most simple and reasonable explanation of the above results suggests the following:
I Vertebral artery elongations during neck manipulations are always well within the elongations observed
within the normal range of motion.
II Vertebral artery elongations during neck manipulation are always much smaller than the elongations
that cause first mechanical failure.
III Finally, for the elongations observed during neck
manipulation, there are no measurable forces (stresses)
acting on the vertebral artery.
Based on these, to our knowledge, first ever results of
vertebral artery mechanics during high-speed, low-amplitude treatments, we draw the following conclusion:
I It seems highly unlikely that a spinal manipulative
treatment to the neck tested here can cause mechanical injury to a normal vertebral artery.
…. and all those patients who had a stroke following chiro have imagined it, particularly those who died from it?!?
Edzard, just for once consider the possibility that at least some of those people you refer to and who were tragically affected were going to have a stroke or spontaneous VA regardless of the manipulative procedure? Particularly those applied by a skilled clinician who is managing to stay within the physiological range of motion. I refer back to your comment about a 30 day window after manipulation. Many things happen in 30 days. This ought to at least cast some doubt on the tenacity with which you refer to manipulative therapy applied to the upper cervical spine as causal and it is ok for you to change your mind in the light of new scientific evidence.
Stefaan
@ Stefaan Vossen
Bearing in mind that there are no reliable screen methods available to chiropractors, if some of those people were going to stroke out anyway, why potentially exacerbate things with neck manipulation when safer options are available?
Please Blue wode enlighten us as to how we could ” potentially exacerbate things with neck manipulation when safer options are available?” when the research shows more stress is applied to the VA with simple diagnostic tests or simple head rotation. And exactly what are these safer options?
That comment tells me, dear Blue Wode, that you have no day-to-day experience of clinical reality. If you had, you would know that “shit happens”, both in the positive (unexplained improvements-which is what you seem to attribute the success of many clinicians to) and negative sense. No clinician worth their salt freezes at this notion. cclinical life is about embracing humbly the fear of uncertainty. It is sometimes scary that not everything can be explained or anticipated. This doesn’t mean that it shouldn’t be sought to be understood or explained, but that is not really where you have been coming from for all these years is it? The studies of studies, the analysis of analyses, they haven’t contributed much other than fodder for layers of assumption and biased rhetoric all pointing in the same direction. No-one has all the answers, and yes, the poly-causality of back pain, neck pain, headaches etc is a complicated field. which is why it is best left to people who do nothing else all day.
Stefaan
Stefaan Vossen wrote: “Clinical life is about embracing humbly the fear of uncertainty.”
Not to the detriment of patients, it isn’t. You cannot escape the fact that a large chunk of the chiropractic community puts prejudice and/or profit before the precautionary principle.
On another matter, your patronising manner and veiled ad homs do you no favours.
Fodder for what lawyers? Biased rhethoric? No, it’s the evidence that points in a direction which you feel uncomfortable with. No-one has all the answers, but some try to discover the truth, while others seem to be hiding it, I fear.
So you think this piece of very specific research is of no use? Even though it shows smt puts no strain on a vertebral artery you still feel that a sometimes spontaneous event is caused by the chiropractor? How very scientific of you prof. Stick to your own views what ever the evidence Putin front of you.
i do not say that there is no doubt about the risks involved but the precautionary principle holds that, as long as there is strong doubt, we must assume the worse for the benefit of the patient.
Isn’t it up to the patient to evaluate those risk/benefits for themselves? The precautionary principle also requires evaluation of the risks of alternative options PRIOR to it being heralded as a reason. What you seem to be doing dear Edzard is advising people to take the car to avoid the plane….
Not really, Stephaan. The risks and benefits of planes and cars are well documented, while those of SMT are not. To use your [not very well-fitting] analogy, you are advising people to use a means of transport for which we have no proof that it gets you from A to B and about which we suspect that some people suffer terrible hardship when using it.
What about vaccinations and this “precautionary principle”. You will say benefits outweigh the risks, however they did not know that when Andrew Wakefield first raised his concerns about the MMR , you would have thought at the very least they would have replaced the multiple vaccine with the single version if this precautionary principle was acted on, for rare incidence of adverse reactions.
Between 2000 and 2003 there were around 30 unexplained deaths withing 24 hours of receiving the DTaP according to epidimiologist Richard Meade, vaccine was not withdrawn until 2004 even though they suspected it was not very effective at preventing pertussis, little explanation was given when it was replaced with the five in one vaccine. Definitely not the precautionary principle.
Again I invite you to come into my practice and monitor every patient I perform a cervical adjustment on, which is nearly all of them as you dont believe I have never had a serious adverse event post spinal adjustment and only a handful of occasions where a client felt worse afterwards ( usually because they forgot to use ice). I am telling you I am the Roger Federer of spinal adjusting so surely you would want to burst my bubble and show the world how given unfettered access into a chiropractic clinic you were able to confirm your suspicions. Your chances of proving your point are probably even greater with a “maverick” like me who is not even on the chiropractic register and who you would think is very cavalier in his approach to patient care. If arterial dissection are as common as you say you will have an idea how many patients you will need to observe before something shows up, I am pretty sure I can persuade colleagues to cooperate to get the numbers you require. I cant do better than that, so either put up or shut up if you are serious about doing research.
Richard:
1) I did not know you were an anti-vaxer as well!
2) Even if the the precautionary principle were violated in one area of healthcare, this would not be a carte blanche for doing so elsewhere.
3) Why do you think I should have an interest in debunking you? Even if anyone did, the chiros would agree with the sceptics in muttering “I told you so!”
4) When or where did I say that dissections were common?
5) I will not shut up but you should consider it.
1) What was anti vaccination about anything I said above, I am skeptical about the health claims made about vaccinations for the reasons I outlined. Have you a “Health Scientist” no concerns at all about side effects to vaccinations ? Or even wonder about the role disease played in the evolutionary development of the immune system perhaps you think the immune system has ceased evolving? Are you trying to improve health interventions through science or just another bloke who likes winding up CAM practitioners.
2) I agree.
3) I have never seen a serious adverse event in practice or know anyone who has had. Mr Stewart’s experience is a result of incompetence not because maintaining spinal joint function is dangerous. I have offered you the opportunity to see chiropractic in action and monitor the results. So dont then tell me then you know what goes on in my practice, you dont and you have no interest in finding out, fair enough. I am sure your right, the medical wing of the profession would be delighted if I hurt someone, they have gone as far as hiring Private I’s to pose as patients. You see not requiring the endorsement of the GCC has upset a few who would like to be able to tell me to cross my ts and dot my I’s . Nevertheless you could then ask were you did find bodies in my celar, how is Richards adjustment different from other AECC graduates.
4)Have you not said in the past, arterial dissection was common after manipulation? So its not then, i did not think it was.
5) If you want me to shut up, just answer some of the questions I have asked above, see how politly I have dealt with each numbered point you raised. So i will try again; Why did your definition of Evidence Based Medicine in Trick or treatment leave out “patient values” and “practitioners experience” ?
A master in health promotion? I am impressed.
Richard, you provide excellent comic relief – first you tell me to shut up, then I return the compliment and now you stress that you are so polite. Please keep your comments comming, few people have the comic talent you have.
Edzard,
Why don’t you just answer the man’s questions?
What do you have against him. He is just asking you something which it seems to me you are trying to avoid.
I too am waiting for a proper response.
What question? He tends to ask multiple, and when I answer them he multiplies them again.
About TRICK OR TREATMENT, the answer is simple: this book was not about EBM in the sense he puts it; it was about the external evidence as it pertains to alt med. This is clearly set out in the book. If we had wanted to write about patients’ preferences and experience, we would have used a different approach and written a different book. I am sure Richard knows that; he just wants to wind people up – and this is why answering such questions is rather futile.
Reading through some of these comments, some skeptics who are actually not practicing themselves sound like they are living in an idyllic Stepford Medics World where every health pro is honed to perfection with impeccable mind, manners, instant rapport with everyone and is able to treat his/her patients with utmost care, courtesy, kindness, time and endless budgets.
All her/his treatments have been rct’ed to perfection with every variable covered and safe, all outcomes predicted with pinpoint accuracy and the patients having had their independent minds neutered, are submissive and docile and would not dream of taking their destiny into their own hands and try unchartered territories.
With the advent of lifelike robots looming ever so closer by the engineers, we may be getting closer to their dream world…
Maritin: what are you trying to say? Should only people who practice a particular treatment comment on it? Think this trough; then, if we are talking quackery, only quacks would be allowed to voice their concerns!?!
….independent minds neutered??? What’s this supposed to mean? People who believe in evidence want nothing of the sort; they might , however, want to protect patients from quacks. There is plenty of choice between effective treatments, isn’t there?
Unfortunately for many back/neck/shoulder ache etc sufferers, there aren’t “plenty of choices between effective treatments” as so called treatments are their first port of call on the NHS and after many years, tears and disillusionment with the system do they like me, on the rare occasion, discover that there are chiros with wonderful hands and knowledge about the back and able to make years of pains disappear like magic.
If this is the kind of woo they are offering, bring it on!!!
Some chiropractors have failed to realise what an accolade it is to have someone like professor Ernst giving his time and energy to studying our profession and indeed CAM. Challenging scientific minds is vital for the progression of science. It is not something we should fear, but rather embrace it as we strive towards understanding the natural world. Professor Ernst please do not take offence from some of the strong views of members of the chiropractic profession – they simply share your passion to understand this subject. What I would hope for is that we could sit down as observers of science and hold intelligent conversations about the known and unknown. It is wrong to think one is vindicated in such debates, as the prize of knowledge is shared on all sides. I hope this is our shared vision and something we should strive for.
P.s. blog comments don’t count.
Martin, what I and many like me fail to undestand is this: if chiros with their wonderful hand and knowledge are truly able to make certain types of chronic pain disappear, why is that phenomenon not much clearer reflected in the reliable evidence, e.g. Cochrane reviews? I know nobody who would object to helping patients – quite to the contrary. The tension exists mostly because your anecdotes are not confirming our evidence and vice versa.
If the effects are as obvious and convincing as you describe them, why are the reliable trials not confirming your impression? Why the discrepancy? How can the benefit all but disappear, if it is put to the scientific test? And if the effects are so good as you describe them, do we all not have a duty to demonstrate them beyond reasonable doubt so that all patients [not just the ones who happen to find their way to you] with a given problem will eventually be able to benefit from these skills and knowledge?
Sceptics are not nihilists; they doubt assumptions, anecdotes, clinical experience for very good and plainly obvious reasons; they aim to make progress by insisting on evidence for the benefit of patients.
“If the effects are so good as you describe them, do we all not have a duty to demonstrate them beyond reasonable doubt”
I have a masters in “Health Promotion” from Brunell University and i must have missed the lecture “health interventions that are certain to work”. There will always be some doubt in clinical science, thats why clinical experience is so important in assessing research and you did not cover it in your book Trick or treatment.
Maybe science is not so spectacular at either side of the fence so much so that about 7.6 million working days were lost due to work-related back pain and other musculoskeletal disorders from 2010 to 2011.
Musculoskeletal injuries such as neck strains and back pain are in 3rd and 5th position for the top five causes of long-term absence according to the Telegraph.
Almost 10 million Britons suffer pain almost daily resulting in a major impact on their quality of life and more days off work. The cost of back pain to the exchequer is estimated to be in the region of £5billion per annum.
Does this sound like “there is plenty of choice between effective treatments”?
No question, we are all pretty lousy at treating back or neck-pain – all the more important then to make progress; and that is made by science not by banging on about pseudo or anti-science.
What a load of rubbish. Treating back or neck pain is about establishing the right course of therapy for the right problem, then evaluating that therapy as best as you can. Where would the science of back and neck pain be without therapies that have evolved to help them?
Jesgol wrote: “Professor Ernst please do not take offence from some of the strong views of members of the chiropractic profession – they simply share your passion to understand this subject.”
I disagree. Ad hominems and derogatory remarks, the likes of which Prof. Ernst has experienced from numerous chiropractors, seem to indicate that many chiropractors have a deep fear of being wrong, or being “found out”.
I suspect that you’ve forgotten the original topic of this blog post which describes (1) how the British Chiropractic Association (c.1800 members) unsuccessfully *sued* Simon Singh for writing (correctly) in the Guardian that the British Chiropractic Association happily promoted bogus treatments without a jot of evidence to support them, (2) how a chiropractor complained unsuccessfully to the Press Complaints Commission about the Guardian over comments it made about one of Prof. Ernst’s own papers which demonstrated that many trials of chiropractic fail to mention adverse effects, (3) how a chiropractor complained unsuccessfully to Prof. Ernst’s university about his alleged “research misconduct”, and (4) how another chiropractor, *supported by the World Federation of Chiropractic*, complained unsuccessfully (for the fourth time) directly to Prof. Ernst’s university over alleged fabrication of data from the 1990s. That all serves to confirm the suspicions of many that chiropractors, in general, have been trying to silence valid criticism of themselves rather than engaging willingly in constructive, *public* debate.
As chiropractors depend on chiropractic being accepted as a legitimate healthcare intervention in order to continue to earn a living – and their critics don’t – it’s perfectly obvious what’s going on.
What’s that?
The strong views of chiropractors are due to the treatment they have been given; the taunting, jeering, deride, ridicule, gibes and insults they have endured while they are trying to do their best to help public suffering.
Instead of scoring points off each other as to who won the most court cases, we need to concentrate on the 10 million sufferers and the lack of science in treating musculoskeletal injuries.
As Edward magnanimously conceded “No question, we are all pretty lousy at treating back or neck-pain – all the more important then to make progress…” science is ill equipped to deal with the avalanche of back ache sufferers; you can rct till you are blue in the face, call each other names, score points on court cases and it will do little to advance the course of science.
What will help though is turning past paradigms that are obviously not working for us on its head and go boldly where no man has gone before and analyse the chink of success anyone is having and build on it. That is how evolution works.
Chiropractors mostly get all the “left overs” that time or the NHS has not been able to heal. Their successes therefore are all the more important. And successes they do have or they would not be able to carry on with their practices which I believe are thriving.
But at the end of the day, there are 10 million sufferers that NHS can not cope with and 1800 chiros. Maybe the subject of the discussion should be the inadequacy of the system….
Martin, maybe you should read the answers already given – they explain what’s wrong with your arguments. This:
is what chiropractors should ask themselves. If their top priority was providing effective help, that’s what they would ask themselves, but my guess is they’re more concerned about their own income than about finding out if their treatments really work or if what they’re seeing is just placebo effects and confirmation bias.
We are a long way from having the perfect rct’s as far as pain and brain is concerned.
It is one of the last unchartered fronteers of the human body and nobody has a complete map yet. That is why the figures for sufferers are in humangous with very little help available.
The few trials that Edzard or anybody else have made are very preliminary and far from perfect interpretation as we do not know the science behind it yet.
Martin wrote: “The strong views of chiropractors are due to the treatment they have been given; the taunting, jeering, deride, ridicule, gibes and insults they have endured while they are trying to do their best to help public suffering.”
I would venture that chiropractors have brought much of that upon themselves.
Martin wrote: “Chiropractors mostly get all the “left overs” that time or the NHS has not been able to heal. Their successes therefore are all the more important. And successes they do have or they would not be able to carry on with their practices which I believe are thriving.”
FYI, many of those perceived chiropractic successes could easily be attributed to the ‘carpet thickness’ factor and other non-specific effects:
http://www.ebm-first.com/chiropractic/the-meade-report-criticism/1194-peter-dixon-chair-of-the-general-chiropractic-council-seems-to-be-a-bit-careless-about-evidence.html
As for your belief that chiropractic practices are thriving, that’s definitely not the case in the US where chiropractic services have managed to deliver to, at the most, only 9% of the population – a figure which has now dropped to 7% and is, apparently, still declining.
Martin wrote: “…at the end of the day, there are 10 million sufferers that NHS can not cope with and 1800 chiros. Maybe the subject of the discussion should be the inadequacy of the system…”
Or maybe the discussion should simply take the form of an acknowledgement that many GPs unload intractable, self-limiting cases on chiropractors for placebo treatments. As someone once said, that would not really be an endorsement of chiropractic as much as an acknowledgment that chiropractic clinics are repositories for people who really need no treatment (with the hope they will not be harmed).
RCT’s themselves have come into question lately with the drug companies finding out that their results are anything but consistent across the board, from location to location and in different countries as they are increasingly going global. And as far as anything that involves pain, the results are even less clear with old stalwarts like Prozac having different results to before.
The conclusion is that the gold standard is open to too many biases by the clinicians and public alike and can be erratic; what we need is a platinum standard which people are working on it right now.
On top of that they have also discovered that the placebo effect can be a source of treatment by itself and again, there are people studying it to see how it can be incorporated into medicine with huge grants from the gov in US.
The latest is that the placebo effect has a genetic structure involving the COMPT gene:
“The investigating team used blood samples to look at what variant the individual had of the catechol-O-methyltranferase (COMT) gene. This plays a role in the dopamine pathway, a chemical known to produce a feel-good state.
Paper author Dr Kathryn Hall, from the Beth Israel Deaconess Medical Center (BIDMC), said this gene had been chosen because “there has been increasing evidence that the neurotransmitter dopamine is activated when people anticipate and respond to placebos”.
The researchers found individuals with a COMT variant that triples the amount of dopamine in the front of the brain felt no improvement without treatment but an improvement with the placebo acupuncture.
Ted Kaptchuk, director of the Program in Placebo Studies and Therapeutic Encounter at BIDMC, said: “We wanted to tease apart the different doses of placebo.
“We got an effect in individuals with this specific genetic signature for the general placebo, but an even bigger effect in the elaborate placebo where warmer care was given.
“You can really see the advantage of a positive doctor-patient relationship.”
When individual experiences collectively do not match up a few clinical results, it is time to question the rct’s. It seems that they are not perfect in themselves and have got a long way to go before they can be reliably trusted.
Perfect? who said RCTs are perfect? But they are the least biased method we have for assessing efficacy/effectivenes. Or does anyone know a better one?
The moral of the story meanwhile is , if is working for you, keep going to your chiro, acupuncture, etc. It may be working in ways that have not been discovered yet.
I know that I cherish my chiro and will keep on doing so.
Martin, blue wode and prof ernst, no matter what they say, are not interested in research that goes against their individual ideas. They are stead fast in their presumption that chiropractic is dangerous and does not work. I have countered Prof Ernst countless times and offered many pieces of research to show chiropractic is beneficial, and even here when evidence is put infont of them that it extremely unlikely a chiropractic adjustment can damage a cervical artery, do they say “OK I may have been wrong” do they hell, they stick to their same old boring broken record. No amount of evidence will alter their opinion. It really is pointless trying. For some reason they see a chiropractor as a ford focus, every one is the same, and if a ford focus has a brake issue then all ford focuses have a brake issue.
Thank you on behalf of all the patients that have benefitted from chiro care; much appreciated!!!
COUNTLESS TIMES: are you joking? I don’t even know you.
I am a patient who has tried both the system and the chiro treatment and read your book and all the evidence you have provided and studied the rct’s to see how fallible they are before I had chiro treatment and continue to do so to hear the latest developments.
Thank you for pointing out “Perfect? who said RCTs are perfect?” and that “No question, we are all pretty lousy at treating back or neck-pain..” for your readers. It clears two points that some of your readers seem to be confused about.
martin wrote: “…the placebo effect can be a source of treatment by itself and again, there are people studying it to see how it can be incorporated into medicine with huge grants from the gov in US”
In the meantime, the blanket approach which you seem to be suggesting (i.e. treating patients irrespective of the quality of evidence) is unethical as there is no such thing as a placebo responder (someone who always benefits from placebo) and a placebo non-responder (someone who never benefits from it). As Prof. Ernst has pointed out previously, this unreliability makes it problematic to count on placebo effects in clinical practice:
http://www.ebm-first.com/a-close-look-at-alternative-medicine/163-mind-over-matter.html
martin wrote: “The moral of the story meanwhile is, if is working for you, keep going to your chiro, acupuncture, etc. It may be working in ways that have not been discovered yet.”
The *real* moral of the story is that as reliable screening procedures are often not available to CAM therapists, and there are serious risks associated with many CAM treatments (particularly chiropractic), it is usually not possible to produce favourable risk/benefit assessments. With regard to chiropractic, as valid informed consent procedures are known to be largely ignored by chiropractors, many patients will be unwittingly risking their time, money, and in some cases lives, by submitting themselves to ‘care’.
“With regard to chiropractic, as valid informed consent procedures are known to be largely ignored by chiropractors,” could you show me evidence of this please blue wode, we have discussed this in the past and yet you learnt nothing? Show me the evidence to back that statement up and again I’ll prove you wrong.
fedup wrote quoting me: “With regard to chiropractic, as valid informed consent procedures are known to be largely ignored by chiropractors,” could you show me evidence of this please blue wode, we have discussed this in the past and yet you learnt nothing? Show me the evidence to back that statement up and again I’ll prove you wrong.”
Here you are:
Consent or submission? The practice of consent within UK chiropractic
In this recent investigation which focused on approaches to consent of a small sample of practicing UK chiropractors, only 23% reported that they always discussed serious risk with their patients.
J. M. Langworthy and C. le Fleming, Institute of Musculoskeletal Research and Clinical Implementation, AECC, UK (Journal of Manipulative and Physiological Therapeutics, January 2005)
http://www.ncbi.nlm.nih.gov/pubmed/15726031?dopt=Abstract
Consent: Its Practices and Implications in United Kingdom and United States Chiropractic Practice
Results from this survey suggest a patient’s autonomy and right to self-determination may be compromised when seeking chiropractic care. Difficulties and omissions in the implementation of valid consent processes appear common, particularly in relation to risk.
Langworthy JM, and Cambron J, Institute for Musculoskeletal Research and Clinical Implementation, [AECC], Bournemouth, UK (July-August 2007)
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17693332&ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Chiropractors have an ethical duty to tell their patients about risks
The Bournemouth team sent questionnaires about risk-related issues to 200 randomly selected UK chiropractors and received 92 responses. Their results show, among other things, that “only 45% indicated they always discuss [the risks of cervical manipulation] with patients … ” In plain language, this means that the majority of UK chiropractors seem to violate the most basic ethical standards in healthcare. If we assume that the 92 responders were from the more ethical end of the chiropractic spectrum, it might even be the vast majority of UK chiropractors who are violating the axiom of informed consent.”
Prof. Ernst, The Guardian Science Blog (12th July 2011)
http://www.guardian.co.uk/science/blog/2011/jul/12/chiropractors-ethical-duty-patients-risks?CMP=twt_fd
And before you do please list the areas where chiropractic adjustments could be dangerous, remebering I have produced evidence to show chiropractic neck adjustments do not damage cervical arteries. If you are going to ignore that piece of research I would like to know your reasons. If you continue to “think” chiropractic adjustments cause vads, please give an example of the chiropractic adjustment you have evidence to show is most likely to cause these injuries. Then show me the evidence that backs up your statement by providing me with the numbers of chiropractors that use those types of adjustments who then do not get valid informed consent. Should a chiropractor who uses a technique where there is absoluely no evidence of injury, vad or otherwise, get the same informed consent as those who use adjustments that you have evidence may be harmfull? What is your expert opinion on say an activator chiropractor? should they get the same informed consent as a gonstead chiropractor? If not why? If yes why?
fedup wrote: “And before you do please list the areas where chiropractic adjustments could be dangerous, remebering I have produced evidence to show chiropractic neck adjustments do not damage cervical arteries. If you are going to ignore that piece of research I would like to know your reasons.
I will not be placing any credence by the piece of research that you cited because it is far from convincing. Note the use of the words “…does not appear to place undue strain on VA…does not seem to be a factor in vertebrobasilar injuries”.
Also, here are my other comments about it which I posted four days ago:
Quote
“Until more is known, the precautionary principle still applies, i.e. the risks of cervical SMT continue to outweigh any perceived benefits. Furthermore, even if cervical SMT was ultimately proven to be safe, there are still other harms from chiropractic treatment to consider including decreased use of immunisation due to misinformation given to parents, psychological harm related to unnecessary treatment, psychological harm caused by exposure to false chiropractic beliefs about ‘subluxations’, and financial harm due to unnecessary treatment.”
fedup wrote: “If you continue to “think” chiropractic adjustments cause vads, please give an example of the chiropractic adjustment you have evidence to show is most likely to cause these injuries. ”
I have no idea what types of chiropractic adjustments cause VAD injuries. Chiropractors use many different techniques (around 200 as far as I know), some of which will involve manipulation of the cervical spine, so perhaps you could list the specific names of ones that can cause harm. What I do know, however, is that there is almost certainly massive under-reporting of serious complications caused by chiropractic treatment – something which evidently is not helped by the fact that in the US chiropractors don’t have to report adverse events because of a loophole:
http://www.ebm-first.com/chiropractic/risks/1842-letter-from-britt-harwe-president-chiropractic-stroke-awareness-group-csag.html
In the UK things aren’t much better:
http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1888-british-chiropractic-association-members-attitudes-towards-the-chiropractic-reporting-and-learning-system-a-qualitative-study.html
fedup wrote: “What is your expert opinion on say an activator chiropractor?”
In view of the evidence, I suspect that history will view such an individual as a parlour trick fan. Currently, I would agree with the following review:
“In conclusion, while uncontrolled case studies have shown that the Activator maybe effective at reducing back pain without any firm proof (such as a well designed RCT study), I would agree with Prof Ernst’s view that this type of intervention has no sound scientific bases and is “at best, an expensive placebo”.”
Prof Richard Appleyard, Australian School of Advanced Medicine, Macquarie University. Friends of Science in Medicine (October 2012) [pdf]
http://www.scienceinmedicine.org.au/images/pdf/revchirodev.pdf
fedup wrote: “should they get the same informed consent as a gonstead chiropractor? If not why? If yes why?”
Chiropractic is a narrow field compared to medicine so there are really no excuses for not disclosing the scientific evidence and reported risks to patients. IMO, what patients require to be told is really quite simple and has already been proposed by Prof. Ernst and his co-author, Simon Singh, on page 285 of their book, Trick or Treatment? Alternative Medicine on Trial:
Quote
“Warning: This treatment carries the risk of stroke or death if spinal manipulation is applied to the neck. Elsewhere on the spine, chiropractic therapy is relatively safe. It has shown some evidence of benefit in the treatment of back pain, but conventional treatments are usually equally effective and much cheaper. In the treatment of all other conditions, chiropractic therapy is ineffective except that it might act as a placebo.”
You should not take all scientific statements/rct’s as gospel truth. Scientists are fickle and known to change their minds when better evidence emerges and books tend to sensationalise facts to sell:
“It has shown some evidence of benefit in the treatment of back pain, but conventional treatments are usually equally effective and much cheaper.” EE 2009 issue
“No question, we are all pretty lousy at treating back or neck-pain – all the more important then to make progress; …. EE 2012.”
“Some evidence of benefit” is better than nothing at all (presuming impossibly perfect trials and that we know all there is to know about pain) especially as I repeat, there are “7.6 million working days were lost due to work-related back pain and other musculoskeletal disorders from 2010 to 2011, mussculoskeletal injuries such as neck strains and back pain are in 3rd and 5th position for the top five causes of long-term absence according to the Telegraph and almost 10 million Britons suffer pain almost daily resulting in a major impact on their quality of life and more days off work. The cost of back pain to the exchequer is estimated to be in the region of £5billion per annum.”
I personally weighed the risks of having an operation which did not guarantee success and carried serious risks of 1 in 100 including permanent paralysis to chiro which after reading all available info, I reckoned to be less than the risk I was taking actually getting there.
Chiro has been put under a microscope in isolation with the real world and and is expected to be perfect which is totally unfair.
The only losers here are the patients who are scaremongered and made to endure pain unnecessarily.
Martin wrote: “Scientists are…known to change their minds when better evidence emerges.”
Very true.
Martin wrote: “Chiro has been put under a microscope in isolation with the real world and is expected to be perfect which is totally unfair.”
It’s not expected to be perfect, but it is expected to be able to offer something of good value that can be added to the medical mix. All that it has going for it so far (and it’s been nearly 120 years) is some slim evidence for spinal manipulation for low back pain – although let’s not forget that spinal manipulation isn’t true chiropractic and is also performed – usually more judiciously – by other manual therapists.
Martin wrote: “The only losers here are the patients who are scaremongered and made to endure pain unnecessarily.”
I disagree. Patients are winners when they have the full facts in front of them to enable them to make informed decisions about their healthcare. That is what Prof. Ernst and his colleagues continue to try to give them, and they should be commended greatly for their efforts.
“That is what Prof. Ernst and his colleagues continue to try to give them, and they should be commended greatly for their efforts.”
I am sure you are all meaning well, but from a patient’s perspective, more often than not it sounds like they are being called names, insulted, accused of money grabbing and persecuted as if they are aliens from another planet instead of making use of their wealth of knowledge and experiences and building on it or taking it into another level.
As it is, the system is nearly useless, the chiropractors have given up bar a few to enter into discussion because they think it is futile while record numbers of patients are suffering.
Otherwise, I commend you!!!
I will applaud the efforts made by Ernst and his colleagues to reveal as much infomation as possible and therefore allow patients to make informed decisions. However, where he seems to fall short is in his applying of the same standards to all professions. Other professions use techniques like acupuncture and they rarely get mentioned when criticising acupunture. Also he neglects to mention the following side effects in his subsequent article on acupuncture on this blog
In 2001, a study ascertained the incidence of adverse events related to acupuncture treatment. The study noted serious adverse events including lost or forgotten needles in the patient, skin infection, long-lasting pain at the site of needle entry (greater than two weeks), fainting, nausea and vomiting, lethargy, long lasting disorientation (greater than one day), anxiety, headache, numbness in the skin, slurred speech, and worsening of symptoms including back pain, fibromyalgia, shoulder pain, vomiting, and migraine.49
In 2011, a systematic review of systematic reviews examined reported incidents of serious adverse effects occurring after acupuncture treatment. Most patients had been to an acupuncturist for relatively minor problems. Thirty-eight cases of infection were reported, resulting in abscesses in the skin and spine, infected joints, necrotizing fasciitis, syphilis, and HIV. Forty-two cases of organ trauma were reported, including pneumothorax (from which multiple patients died), spinal cord injuries resulting in permanent neurological deficits, nerve injuries, bleeding into the carpal tunnel, broken needles in the neck, aneurysms in arteries, cardiac tamponade, and sadly the traumatic creation of a pathway (fistula) between the aorta and the intestine (resulting in death). Other adverse effects included seizures, different nerve injuries, and even skin cancer due to chronic irritation from repetitive needle insertion. All of these conditions which didn’t kill the patient ultimately required conventional medical treatment for management.
http://www.sciencebasedmedicine.org/index.php/acupuncture-practice-acts-legalized-quackery/
@ A N Other
Whilst I agree that it was probably remiss of Prof. Ernst not to mention complications resulting from acupuncture in his blog post, the complications – the most serious of which are 38 cases of infection and 42 cases of organ trauma (which include some deaths) – are substantially less than the 700+ serious complications (including fatalities and permanent paralysis) of chiropractic treatment which are on record.
As Prof. Ernst and Simon Singh say on p.285 of their book, Trick or Treatment? Alternative Medicine on Trial, acupuncture is a largely safe treatment when practiced by a trained acupuncturist. On the other hand, no trained chiropractor possesses a reliable screening method for detecting patients who might be predisposed to a catastrophic vertebral artery dissection as a result of manipulation of the cervical spine.
@ Blue Wode
To paraphrase your self from below and with regards Edzard Ernst article on this blog
“it is uncertain whether acunpuncture generates more benefit than harm for patients” and under this statement if the risk is greater than the benefit, the treatment should be rejected. In addition, it has been commonly noted that side effects are under reported, so the number could be greater.
Also, to state that one ineffective treatment has caused more deaths than another ineffective treatment doesn’t make it any less of a mistake to not have included the complications associated with acupuncture. Remember it is all about giving the patient all the information possible to make an informed consent.
A N Other wrote: “To paraphrase your self from below and with regards Edzard Ernst article on this blog “it is uncertain whether acunpuncture generates more benefit than harm for patients” and under this statement if the risk is greater than the benefit, the treatment should be rejected.”
I take your point, although I suspect that the main risks of acupuncture (infection, misplaced/lost needles) would pretty much vanish if the practitioners were more vigilant, whereas the major risk with chiropractic seems to lie with the lack of a reliable screening method prior to performing a dangerous manouevre. IOW, I can see why a favourable risk/benefit assessment might be produced for acupuncture treatment, but not for chiropractic neck manipulation (which, let’s not forget, is frequently administered to low back pain patients).
A N Other wrote: “Also, to state that one ineffective treatment has caused more deaths than another ineffective treatment doesn’t make it any less of a mistake to not have included the complications associated with acupuncture.”
Didn’t I say that it was probably remiss of Prof. Ernst not to mention complications of acupuncture in his blog post? Have you raised your concerns in the comments section of the acupuncture blog post? Perhaps he has a reason for the omission.
“I will not be placing any credence by the piece of research that you cited because it is far from convincing.” laughable. you are given evidence and you decide it has no credit? Why? please explain.
“I have no idea what types of chiropractic adjustments cause VAD injuries. Chiropractors use many different techniques” again laughable, it shows your total lack of knowledge and understanding of chiropractic but yet you continue to label “chiropractic” as dangerous.
And please stop quoting from your own website, it just shows you are a biased as Prof Ernst if all you can do is constantly reference your own work.
And how about this from activator. “The Activator Method is one of the most widely-researched chiropractic techniques and the only instrument adjusting technique with clinical trials to support its efficacy. Activator Methods has published hundreds of clinical and scientific peer-reviewed papers, worked with major academic research institutions, and received grants from recognized entities like the National Institutes of Health.”
fedup wrote: “…you are given evidence and you decide it has no credit? Why? please explain.”
I did.
fedup wrote: “And please stop quoting from your own website, it just shows you are a biased as Prof Ernst if all you can do is constantly reference your own work.”
Since when did citing good, scientific evidence become bias?
fedup wrote: “And how about this from activator. “The Activator Method is one of the most widely-researched chiropractic techniques and the only instrument adjusting technique with clinical trials to support its efficacy. Activator Methods has published hundreds of clinical and scientific peer-reviewed papers, worked with major academic research institutions, and received grants from recognized entities like the National Institutes of Health.”
Irrelevant. It’s the quality of evidence that counts at the end of the day and it’s not looking good for the Activator.
“In the meantime, the blanket approach which you seem to be suggesting (i.e. treating patients irrespective of the quality of evidence) is unethical”
I have been to my GP, the specialist and 4 separate physics on the NHS to no avail.. While the chiro sorted my pains for good whether placebo effect or not. Probably not because I physically could not lift my arms back further than my side and my neck froze on several occasions and I had back ache all the time. After a course of chiro, nothing; no pain, no physical limitations whatsoever!
All you have said about the chiros, I felt about the system, yet I don’t see them being vilified to almost pathological proportions. I simply stopped visiting my GP as I though it was a waste of my time.
The fact is rct’s are not infallible and written in stone. A few rct’s here and there are PROVEN to be unreliable in so many ways. Clinicians simply can not cover all the variables and many are brimming with various biases and the whole fabric of rct’s are undergoing investigation and change.
When you have had pain for decades, you have already tried the blanket approach which the system has been dishing out anyway. A few more is neither here nor there. But there is always the chance that you will get better as in my case.
Apart from that, the chiros also have a more personal approach; one of the physios that treated me was blind and left me to smoulder under some lights, the other put me under a machine after which I ached like hell and spent the most miserable Christmas of my life. Another actually looked at me and tried some alignment which gave a little relief and I had good rapport with her but the next time I went I was told I could not have her or the same treatment; I was not allowed to choose my own therapist! The story goes on and on.
With the chiro, I got personal attention, and actually what she described made sense. After many sessions, it really worked. Would I have minded if it didn’t work?
No, I was quite used to treatments that did not work.
Was it worht my while and my money?
Absolutely.
Would I recommend them?
Positively!
Do I care whether my case is anecdotal?
Not a hoot!
martin wrote: “The fact is rct’s are not infallible and written in stone. A few rct’s here and there are PROVEN to be unreliable in so many ways. Clinicians simply can not cover all the variables and many are brimming with various biases and the whole fabric of rct’s are undergoing investigation and change.”
That’s a two-way street. What you are saying would also then have to apply to RCT studies by chiropractors which claim to show benefits of chiropractic treatment (and possibly other studies that claim to show that there are no risks associated with neck manpulation).
martin wrote: “Do I care whether my case is anecdotal? Not a hoot!”
This blog critically evaluates CAM from a scientific perspective. Whilst I’m glad that you felt that you experienced relief from you “many” chiropractic sessions, it really counts for very little.
“This blog critically evaluates CAM from a scientific perspective. Whilst I’m glad that you felt that you experienced relief from you “many” chiropractic sessions, it really counts for very little.”
Maybe that is the problem of science these days and the lack of headway in treating musculoskeletal problems; they are not interested in the individual but more concerned about statistics.
Well, statistics are made up of anecdotes but collectively they can be manipulated every which way.
As famously quoted: There are three kinds of lies; lies, damn lies and statistics.
martin wrote: “Maybe that is the problem of science these days and the lack of headway in treating musculoskeletal problems; they are not interested in the individual but more concerned about statistics.”
I tend to agree with you. I suspect that the problem is that many musculoskeletal conditions are psycho-social in origin and are therefore really only amenable to ‘tea and sympathy’ – i.e. the non-specific (placebo) effects brought about by perceived compassionate touch and attention rather than the actual mechanics of an intervention such as spinal manipulation.
“tea and sympathy”, you must be joking! That must be the most insensitive thing I have ever heard!
Long term back ache drives people insane; they get depressed and stressed and this leads to other psychological and physical complications.
The advantages of a positive health provider/patient relationship have been proven to increase your dopamine, serotonin and all the brain opiods. People commit suicide and become drug addicts because of the lack of these!
Depression which almost always accompanies back ache can be lethal and feel as painful as any bodily injury and drives people to take desperate measures.
Alternative therapies which provide psychological relief are now becoming an integral part of treatment in many medic’s repertoires from pain management to psychological disorders to cancer.
Edzard’s efforts -while appreciated for accentuating that improvements need to be made – concentrate nearly always on the negative and very few positive sides of alternative therapies.
Fortunately times are moving on, and alternative therapies are being seen in a new light by a new breed of health professionals.
And that is how it should be.
martin wrote: “tea and sympathy”, you must be joking! That must be the most insensitive thing I have ever heard! …therapies which provide psychological relief are now becoming an integral part of treatment in many medic’s repertoires from pain management to psychological disorders to cancer.”
Isn’t that a bit of a contradiction?
martin wrote: “Edzard’s efforts -while appreciated for accentuating that improvements need to be made – concentrate nearly always on the negative and very few positive sides of alternative therapies.”
That’s because, as a scientist, he is required to *critically* evaluate data. As he says:
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“Although my estimate of how much of CAM is evidence-based draws on a critical evaluation of the available evidence, it still presents a rather optimistic view.”
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3136881/
Isn’t it positive to discover what doesn’t work, so that scientific focus can be turned to other possibilities?
Psychological relief with alternative theraphies is more than “tea and sympathy” which you can get in your corner cafe, is what I meant.
Apologies if I misunderstood!!!!!!!
The rest of what I said still goes….
martin wrote: “Psychological relief with alternative theraphies is more than “tea and sympathy” which you can get in your corner cafe, is what I meant.”
I disagree. Alternative therapies are almost invariably theatrical placebos, therefore they have much in common with tea and sympathy.
But ones that can raise your dopamine, serotonin, brain opiods and by calming your nervous system and stress levels helps improve mental and physical health along with medical interventions.
What other drug does that without side effects and dependency?
That is why alternative therapies are thriving in spite of all the warnings by skeptics!
martin wrote: “…ones that can raise your dopamine, serotonin, brain opiods and by calming your nervous system and stress levels helps improve mental and physical health along with medical interventions. What other drug does that without side effects and dependency? That is why alternative therapies are thriving in spite of all the warnings by skeptics!”
That brings us full circle to the placebo affects of CAM therapies and there being no such thing as a placebo responder (someone who always benefits from placebo) and a placebo non-responder (someone who never benefits from it). As I wrote in a previous comment, Prof. Ernst has pointed out that this unreliability makes it problematic to count on placebo effects in clinical practice:
http://www.ebm-first.com/a-close-look-at-alternative-medicine/163-mind-over-matter.html
They are complementary therapies, ie CAM and quite right do not replace clinical interventions but are an aid to it.
Some practicing medics describe it as a three legged stool; medical interventions, drugs and CAM and believe that they are all integral and dependent on each other for complete “mind and body” interventions which is the new buzz word in clinical circles.
martin wrote: “They are complementary therapies, ie CAM and quite right do not replace clinical interventions but are an aid to it.”
Here’s the problem with that:
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“This argument is a classic straw-man: it deliberately exaggerates the weaknesses of modern medicine and proposes that its defects can be repaired by adding unproven or disproven treatments to the system—after all, alternative practitioners may well have time, empathy, and compassion, but they also employ treatments that are not evidence-based, implausible, or bogus. Few people can deny that mainstream medicine is imperfect. All too often, its limitations are nothing but obvious. Therefore, a growing army of experts has been recruited for doing their utmost to improve it. As a result, we have better healthcare today than ever before in the history of medicine. Compassion has by no means left mainstream medicine and, where it is being neglected, it must be revived not outside but within the system.”
http://blogs.bmj.com/bmj/2012/06/28/edzard-ernst-the-integrated-medicine-straw-man/
And some scientists are in the process of isolating which genes are responsible for which placebo effects. Then all they have to do in future is take a blood sample and figure it out!!!
For example, as I mentioned earlier:
“…The team then used blood samples to look at what variant the individual had of the catechol-O-methyltranferase (COMT) gene. This plays a role in the dopamine pathway, a chemical known to produce a feel-good state.
Paper author Dr Kathryn Hall, from the Beth Israel Deaconess Medical Center (BIDMC), said this gene had been chosen because “there has been increasing evidence that the neurotransmitter dopamine is activated when people anticipate and respond to placebos”.
The researchers found individuals with a COMT variant that triples the amount of dopamine in the front of the brain felt no improvement without treatment but an improvement with the placebo acupuncture.
Ted Kaptchuk, director of the Program in Placebo Studies and Therapeutic Encounter at BIDMC, said: “We wanted to tease apart the different doses of placebo.
“We got an effect in individuals with this specific genetic signature for the general placebo, but an even bigger effect in the elaborate placebo where warmer care was given.”
It is preliminary studies but I expect that in the future, they will be able to tailor the placebo responses with better accuracy.
martin wrote: “…some scientists are in the process of isolating which genes are responsible for which placebo effects…It is preliminary studies but I expect that in the future, they will be able to tailor the placebo responses with better accuracy.
…By that time it is likely to be accepted within the system. Meanwhile, it’s a case of double standards.
All therapies have an incubating period; if we never took a risk and tried anything, there would be little progress.
Before you can trial anything at all, you need an experience, an idea, then a theory, then observation and then trials. Nowadays trials cost $1 billion nowadays to be done properly. And as we are finding out they are still anything but reliable and need improving.
People are not robots, they take calculated risks, the real world is not run in the laboratories by scientists but by people and the choices they make.
Talking of double standards, that is laughable; don’t even go there!!!
“Although placebos have played a critical role in medicine and clinical research for more than 70 years, it has been a mystery why these inactive treatments help to alleviate symptoms in some patients – and not others. Now researchers have for the first time identified genetic differences between placebo responders and non-responders, providing an important new clue to what has come to be known as “the placebo effect.”
Led by investigators at Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School (HMS), the new findings demonstrate that genetic differences that account for variations in the brain’s dopamine levels help to determine the extent of a person’s placebo response, a discovery that not only has important implications for patient care, but could also prove to be of significant benefit to researchers in designing and conducting clinical trials to help determine a drug’s effectiveness.”
If it was not for alternative therapies and people observing that they healed people, progress would never have been made. Science is catching up with people’s experiences. People lead science and science leads people; it is a two way relationship.
Sometimes we find science in the most unlikely places.
With todays health and safety standards in place in labs, penicillin would never have been discovered!!!
martin wrote: “All therapies have an incubating period; if we never took a risk and tried anything, there would be little progress.”
Chiropractic has had an incubating period of nearly 120 years.
martin wrote: “Before you can trial anything at all, you need an experience, an idea, then a theory, then observation and then trials. Nowadays trials cost $1 billion nowadays to be done properly. And as we are finding out they are still anything but reliable and need improving.
True, and very true with regard to CAMs, and chiropractic in particular. It’s worth reading The Scientific Method of Investigation v. The Chiropractic Method of Investigation:
http://chirotalk.proboards.com/index.cgi?action=display&board=presentation&thread=1968&page=1#14531
martin wrote: “People are not robots, they take calculated risks”
Those risks can only be calculated if people are properly informed. With CAMs, and chiropractic in particular, the majority of the time they are not.
martin wrote: “the real world is not run in the laboratories by scientists but by people and the choices they make”
…based on proper information.
martin wrote: “If it was not for alternative therapies and people observing that they healed people, progress would never have been made.”
Alternative therapies cannot take the credit for the progress. There have been many medical interventions which have ultimately been found to be ineffective which have produced placebo responses.
martin wrote: “With todays health and safety standards in place in labs, penicillin would never have been discovered!!!”
That’s debatable. I understand that when Helicobacter Pylori was discovered in recent times it had nothing to do with strict health and safety measures and everything to do with an extended weekend break enjoyed by the researchers.
Take the tale of two cities:
Edzard started out as a medic and noticed that some alternative therapies were having more success than the conventional ones and decided to explore it.
His consequent work determined that they were useless placebos and were “quackery” and had no redeeming features and has a band of followers who spend their time tweeting insulting remarks about alternative therapies.
He has retired early from Exeter uni having his funds dried up, does not conduct any clinical research any more and insists that alternative therapies are the devils work and should be banished from the kingdom.
His proudest achievements are winning court cases along with other sceptics who spend their time finding nothing notably useful about alternative therapies at best.
The other, Ted Kaptchuk started out as an alternative therapist and also noticed that some people were getting better on CAM.
Fast forward now, he along with other investigators at Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School (HMS) have grants from the National Institutes of Health in his country.
Kaptchuk managed to have a major medical breakthrough and demonstrated the genetic differences that account for variations in the brain’s dopamine levels that help to determine the extent of a person’s placebo response.
This discovery not only has important implications for patient care, but could also prove to be of significant benefit to researchers in designing and conducting clinical trials to help determine a drug’s effectiveness.”
I am just saying….
Martin: you do say a lot of nonsense. I never in my life fought a court case. I did not, as a young doc find alt med to be more effective than conventional healthcare. Etc,etc,etc.
And again Blue wode you have dodged the question, do you “think” all chiropractic adjustments can cause vad? yes or no
If there are certain types of adjustments that “you” Think may not be associated with vad should the chiropractor using “in your opinion” safe adjustments get consent regarding a “possible” adverse effect associated with an adjustment they do not use? yes or no.
fedup wrote: “And again Blue wode you have dodged the question, do you “think” all chiropractic adjustments can cause vad? yes or no If there are certain types of adjustments that “you” Think may not be associated with vad should the chiropractor using “in your opinion” safe adjustments get consent regarding a “possible” adverse effect associated with an adjustment they do not use? yes or no.”
I’ve already given you an answer. As I have explained to you in exchanges elsewhere, my reasoning for wanting all chiropractic patients to be informed about the totality of evidence for, and risks associated with chiropractic is based on this:
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“The [NICE] guidelines considered ‘a total of seven RCTs on manipulation/mobilisation techniques’ for evaluating effectiveness. A Cochrane review included 39 RCTs. The methods section of the guidelines informs us that ‘articles not relevant to the subject in question were excluded’. It is unclear to me why so many RCTs of spinal manipulation were excluded from the NICE guidelines…
Perhaps more crucially, the risks were under-estimated. The risk of mild to moderate adverse effects is undisputed even by chiropractors: about 50% (!) of all patients suffer from such adverse effect after spinal manipulations (10). These effects (mostly local or referred pain) are usually gone after 1–2 days but, considering the very moderate benefit, they might already be enough to tilt the risk-benefit balance in the wrong direction. In addition, several hundred (I estimate 700) cases are on record of dramatic complications after spinal manipulation. Most frequently they are because of vertebral arterial dissection (5). Considering these adverse events, the risk-benefit balance would almost certainly fail to be positive. It is true, however, that the evidence as to a causal relationship is not entirely uniform. Yet applying the cautionary principle, one ought to err on the safe side and view these complications at least as possibly caused by spinal manipulations.
So why were these risks not considered more seriously? The guideline gives the following reason: ‘The review focussed on evidence relevant to the treatment of low back pain, hence cervical manipulation was outside our inclusion criteria’. It is true that serious complications occur mostly (not exclusively) after upper spinal manipulation. So the guideline authors felt that they could be excluded. This assumes that a patient with lower back pain will not receive manipulations of the upper spine. This is clearly not always the case.
Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.
The guidelines have a number of serious flaws. I contend that they over-estimated the effectiveness of spinal manipulation and under-estimated the risks of this treatment. If evaluated on the basis of the best current evidence by applying the cautionary principle, one will arrive at the following conclusion: it is uncertain whether spinal manipulation generates more benefit than harm for patients suffering from back pain.”
Ref: Spinal manipulation for the early management of persistent non-specific low back pain — a critique of the recent NICE guidelines, Edzard Ernst, Int J Clin Pract (18th August 2009)
“Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.”
Sorry Blue wode poor response. As you don’t know which chiropractic adjustment “may” be connected to vad how can you possibly come to the conclusion that ALL chiropractors no matter what they are about to do should get full consent and discuss possible vad. To make matters worse you have used a piece by Prof Ernst who is as in the dark as you are as to which chiropractic adjustment may be associated to vad. Why should a chiropractor who uses an activator get informed consent regardin vad? Please explain your thought process. Should a GP give warnings about ibrufen when hes prescribing paracetamol?
“If evaluated on the basis of the best current evidence by applying the cautionary principle, one will arrive at the following conclusion: it is uncertain whether spinal manipulation generates more benefit than harm for patients suffering from back pain.” this statement is pointless if you cannot distinguish between different types of spinal manipulation.
FOR THE MILLIONTH TIME COULD YOU OR PROF ERNST PLEASE PROVIDE EVIDENCE AS TO WHICH CHIROPRACTIC ADJUSTMENTS IS MOST LIKELY TO CAUSE VAD. AS YOU HAVE SAID CHIROPRACTORS USE DIFFERENT TECHNIQUES SO WHY DO YOU PERSIST THAT ALL CHIROPRACTORS ARE THE SAME. WHY DO YOU PERSIST WITH THE BELIEF THAT WE ALL ADJUST NECKS AT EVERY CONSULTATION AND THAT WE ALL ADJUST NECKS IN THE SAME WAY.
It is not up to us to tell you which techniques are more risky than others, it is up to the chiropractic profession to provide this evidence. And the consensus amongst chiros seems to be that high velocity thrusts involving rotation and extension are the ones that cause concern – but you obviously know that. So, why do you want to hear it from me?
No prof Ernst you are the one making massive statements about chiropractors. You should do your job responsibly. You are the one apparently hell bent on informing the public about chiropractic yet you are unable to answer a very simple question regarding chiropractic techniques.
I thought I just answered it! Where did I make “massive statements” on this blog? What is irresponsibe about what I said? And why should the chiroparactic profession not make conclusive statements about the risks of the treatments used?
Ok it really is this simple.
Blue wode and prof Ernst.
Iam a chiropractor who doesn’t use rotational neck adjustments. Am I included in your vad research? Am included in your informed consent argument? Iam a chiropractor who doesn’t work on someone’s neck if they have a low back problem. Yet anybody reading anything by blue wode or prof Ernst would automatically think I did all of the above. Iam not special a large proportion of the chiropractic profession are like me but you would never k ow this from anything written by bw or ee.
Prof Ernst research is dictated by his own bias and because he is unable, or doesn’t care, that there are many types of chiropractic adjustments that have no evidence of injury by simply using the term “chiropractic” shows his ignorance.
fedup wrote: “Iam a chiropractor who doesn’t use rotational neck adjustments. Am I included in your vad research? Am included in your informed consent argument? Iam a chiropractor who doesn’t work on someone’s neck if they have a low back problem.”
Yes. Until chiropractic is standardised, it should be compulsory for all chiropractors to disclose the following to patients:
Quote
“Warning: This treatment carries the risk of stroke or death if spinal manipulation is applied to the neck. Elsewhere on the spine, chiropractic therapy is relatively safe. It has shown some evidence of benefit in the treatment of back pain, but conventional treatments are usually equally effective and much cheaper. In the treatment of all other conditions, chiropractic therapy is ineffective except that it might act as a placebo.”
Ref: Edzard Ernst and Simon Singh, Trick or Treatment? Alternative Medicine on Trial, p.285
BTW, it is possible that the very few chiropractors who don’t use rotational neck adjustments will work in practices alongside chiropractors who do. In such cases their patients are at risk of being treated by neck-adjusting chiropractors in their absence (e.g. when they are off sick or on holiday).
You again show your complete lack of knowledge blue wode, please provide evidence that of the “very few chiropractors” and also please provide evidence that “practices alongside chiropractors who do.”
Those 2 statements by you are nothing but your opinion based on nothing but your own bias and self belief. At least one third of chiropractors in the uk dont use rotational neck adjustments, AT LEAST,do you count that as a few? And before you start about US chiros please check the number of activator chiros working in the states.
As for your second comment about working along side other chiros that adjust the neck differently please provide evidence, but as you have non, that may be difficult.
As usual you will continue “believin” what ever you like no matter how many times you are told.
Plus back to your comment about standardised chiropractic, that is exactly why you cannot label all chiros the same, that is why you haven’t answered my question about a GP who prescribes paracetamol giving advice about ibrufen reactions, and if you think chiropractors will one day “all be the same” ( though for some reason you think we already are) you are seriuosly mistaken, again.
fedup wrote: “please provide evidence that of the “very few chiropractors”…At least one third of chiropractors in the uk dont use rotational neck adjustments, AT LEAST,do you count that as a few?”
It’s a minority, which leaves the majority of chiropractors in the UK using rotational neck adjustments.
Please provide a citation for your “one third” claim.
fedup wrote: “As for your second comment about working along side other chiros that adjust the neck differently please provide evidence”
Please note that I wrote “patients are at risk of being treated by neck adjusting chirorpactors ” which isn’t an unrealistic concern considering that we have already established that the majority of UK chiropractors use rotational neck adjustments.
fedup wrote: “Plus back to your comment about standardised chiropractic, that is exactly why you cannot label all chiros the same”
Indeed, and that’s a massive problem. Why the double standards?
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“…we surely stick out like a sore thumb among professions which claim to be scientifically based by our unrelenting commitment to vitalism. So long as we propound the ‘one cause, one cure’ rhetoric of Innate, we should expect to be met by ridicule from the wider health science community. Chiropractors can’t have it both ways. Our theories cannot be both dogmatically held vitalistic constructs and be scientific at the same time.”
Ref: Joseph Keating Jr, ‘The Meanings of Innate’, Journal of the Canadian Chiropractic Association, 46,1 (2002), p.10.
I have never written or said a word about you; I don’t even know who you are! Perhaps you take yourself a little too seriously?
The argument is weak with this one. “Luke you must tell them of reactions that may happen even if you don’t do whatever it is that may cause the problem. I know they think its rotational neck adjustments that cause the problem and I know you don’t do them but you MUST still tell them about reactions and vads they may get if they see another chiropractor!!!!!”
It’s not a weak argument when you apply the precautionary principle as a safety measure against chiropractic’s lack of standardisation.
“leaves the majority of chiropractors in the UK using rotational neck adjustments” laughable, do you know they are using rotation adjustments? or is that a guess. Which type of adjustment exactly? assumption after assumption.
We don’t have double standards we have different techniques, is that really so hard to understand?
According to David Deutsch the principle is an expression of blind pessimism and inhibits development of knowledge:
Blind pessimism is a blindly optimistic doctrine. It assumes that unforeseen disastrous consequences cannot follow from existing knowledge too (or, rather, from existing ignorance). Not all shipwrecks happen to record-breaking ships. Not all unforeseen physical disasters need be caused by physics experiments or new technology. But one thing we do know is that protecting ourselves from any disaster, foreseeable or not, or recovering from it once it has happened, requires knowledge; and knowledge has to be created. The harm that can flow from any innovation that does not destroy the growth of knowledge is always finite; the good can be unlimited. There would be no existing ship designs to stick with, nor records to stay within, if no one had ever violated the precautionary principle.
— David Deutsch , The Beginning of Infinity, page 201
fedup wrote quoting me: ” “leaves the majority of chiropractors in the UK using rotational neck adjustments” laughable, do you know they are using rotation adjustments? or is that a guess. Which type of adjustment exactly? assumption after assumption.”
Bearing in mind that you wrote that “at least one third of chiropractors in the uk dont use rotational neck adjustments”, do you have good evidence that rest (i.e. two thirds) also don’t? As I said, it’s not an unrealistic concern.
My “assumption”, as you call it (I prefer to call it a concern), is also based on the following:
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“Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment.”
Ref: Spinal manipulation for the early management of persistent non-specific low back pain — a critique of the recent NICE guidelines, Edzard Ernst, Int J Clin Pract (18th August 2009)
Reference (11) is Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35: 544–62. Page 6 of the paper mentions a report that indicates that only 11% of all cervical manipulations are “appropriate” and gives the reference Coulter I, Hurwitz E, Adams A, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica, CA: RAND, 1996:18e43.
fedup wrote: “We don’t have double standards we have different techniques.”
Same thing. You cannot have mechanists and vitalists. They cannot both be right.
fedup quoted: “…There would be no existing ship designs to stick with, nor records to stay within, if no one had ever violated the precautionary principle.”
Poor analogy. Ships have long been recognised as a valuable form of transport, whereas the benefits of neck manipulation remain questionable (and even if there was good evidence for its benefits, it almost certainly would be contraindicated due to the lack of reliable screening methods).
Michael Crichton wrote: The “precautionary principle,” properly applied, forbids the precautionary principle. It is self-contradictory. The precautionary principle therefore cannot be spoken of in terms that are too harsh
You appear to be struggling for reasons to exclude chiropractors from adopting a cautious attitude. I wonder if it could have anything to do with this…
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“If a chiropractor limited his practice to musculoskeletal conditions such as simple backaches, if he were able to determine which patients are appropriate for him to treat, if he consulted and referred to medical doctors when he couldn’t handle a problem, if he were not overly vigorous in his manipulations, if he minimized the use of x-rays, and if he encouraged the use of proven public health measures, his patients would be relatively safe. But he might not be able to earn a living.”
Ref: Stephen Barrett, MD, the ‘Spine Salesmen’ chapter of the book, The Health Robbers: A Close Look At Quackery In America
“struggling” is putting it mildly. Lifting quotes from a wiki article and pasting them without comment as if they are self evidently true, smacks of desperation.
@fed up
Your quote from David Deutsch suggests that you think chiropractors should be free to do whatever they think might help, regardless of whether there is robust evidence that it does and that any injury that might result is justified because it contributes to our sum total of knowledge. Is that what you think? If so, can you see why it is ethically unacceptable to those of us who don’t have a vested financial interest in chiropractic? If not, what is your point with this quote?
The Michael Crichton quote is intriguing. Can you please explain what you understand by it in relation to chiropractic (or in relation to anything, for that matter)?
Fed up
You don’t think that a client should be informed about the possible danger adjustments ? ?
My quotes were nothing more than a way of showing that the pre. principal is not viewed by everyone as the absolute truth and only way of doing things.
“If a chiropractor limited his practice to musculoskeletal conditions such as simple backaches,” I do.
“if he were able to determine which patients are appropriate for him to treat,” I try my best.
” if he consulted and referred to medical doctors when he couldn’t handle a problem,” I do on a regular basis.
“if he were not overly vigorous in his manipulations” I think we have already covered that one.
“if he minimized the use of x-rays,” I don’t take them, never have.
“and if he encouraged the use of proven public health measures,” I do though more often than not a new patient will only visit me after they have exhausted the “proven public health measures”
” his patients would be relatively safe. But he might not be able to earn a living” so I do all of the above, does that mean my patients are safe? and guess what I can even make a living, have done for over 20 years. Again I’m not special there are many more chiropractors like me.
Skeptikat i’m certainly not desperate, maybe exacerbated by the total lack of understanding and blinkered reasoning by certain people. I said this earlier, no matter how much evidence is put infront of some people they hold on to their own beliefs.
are you sure? i have changed my view many times as the evidence changed on a certain subject. have you?
@fed up
“My quotes were nothing more than a way of showing that the pre. principal is not viewed by everyone as the absolute truth and only way of doing things.”
So it was a red herring. But we already knew that.
“I do.” “I try my best.” “I do on a regular basis.” “I don’t take them, never have.”
So? I’m sure that lurking in some dark, rarely-visited corner of your brain is the understanding that the fact that you may limit your practice to musculoskeletal conditions has no bearing on what other chiropractors do or don’t do.
You seem to be conflating a few different issues in your comments here but the dummy-spitting you’ve been doing over how chiropractic is being defined is unjustified and ridiculous.
For example,
“WHY DO YOU PERSIST THAT ALL CHIROPRACTORS ARE THE SAME. WHY DO YOU PERSIST WITH THE BELIEF THAT WE ALL ADJUST NECKS AT EVERY CONSULTATION AND THAT WE ALL ADJUST NECKS IN THE SAME WAY.”
Nobody has suggested any such thing so get over yourself.
Prof Ernst, I have given you evidence that chiropractic manipulation puts no more stress on the vertebral arteries than normal range of movement tests (done by all health care professionals) yet you seem to have said nothing about the study that gives an exact opposite outcome to most of your research ie chiropractic causes vad. Blue wode is even worse he/she has just dismissed the piece for no other reason than he/she doesn’t agree with it. How very sceptical/scientific.
Blue wode also constantly references your piece about informed consent regarding vad/stroke, but again doesn’t seem to grasp the fact that a lot of chiros don’t use rotational adjustments, how can the precautionary principal apply when there is no evidence that certain adjustments cause any harm? None. Now if you had done your research properly and given us a type of adjustment that evidence shows may be associated to vad then that would be a different matter, but you (and blue wode) simply refer to all negative outcomes as “chiropractic2 you need to be specific or your outcomes carry no weight.
And AGAIN blue wode should a GP give advice about possible negative reaction regarding ibrufen when he prescribes paracetamol?
fedup wrote: “Blue wode is even worse he/she has just dismissed the piece for no other reason than he/she doesn’t agree with it.”
How wholly disingenuous of you. I said the following:
Quote
“I will not be placing any credence by the piece of research that you cited because it is far from convincing. Note the use of the words “…does not appear to place undue strain on VA…does not seem to be a factor in vertebrobasilar injuries”.
Quote
“Until more is known, the precautionary principle still applies, i.e. the risks of cervical SMT continue to outweigh any perceived benefits. Furthermore, even if cervical SMT was ultimately proven to be safe, there are still other harms from chiropractic treatment to consider including decreased use of immunisation due to misinformation given to parents, psychological harm related to unnecessary treatment, psychological harm caused by exposure to false chiropractic beliefs about ‘subluxations’, and financial harm due to unnecessary treatment.”
fedup wrote: “…AGAIN blue wode should a GP give advice about possible negative reaction regarding ibrufen when he prescribes paracetamol?”
No, because medicine is largely standardised, unlike chiropractic.
Additionally, MDs are aware that *all* patients taking OTC and/or prescription medications are protected by compulsory Patient Information inserts which invariably list the dose, evidence-based benefits and risks (side effects) of each preparation, and their contraindications. There is no equivalent for chiropractic , and that, together with the lack of standardisation in chiropractic, is why I am in favour of there being a compulsion on all chiropractors to disclose the following to their patients prior to treatment:
Quote
“Warning: This treatment carries the risk of stroke or death if spinal manipulation is applied to the neck. Elsewhere on the spine, chiropractic therapy is relatively safe. It has shown some evidence of benefit in the treatment of back pain, but conventional treatments are usually equally effective and much cheaper. In the treatment of all other conditions, chiropractic therapy is ineffective except that it might act as a placebo.”
Ref: Edzard Ernst and Simon Singh, Trick or Treatment? Alternative Medicine on Trial, p.285
So you ignore the body of the whole study all the parts that show there is no more stress on the arteries than range of movement testing but concentrate on the words “appear” and “seem”? I think you are being “wholly disingenuous” to the authors of the study.
@ fedup
It was *one* study. What don’t you understand about “until more is known, the precautionary principle still applies”?
And I tell you that mechanistic evidence of the sort you quote is firstly not unanimous and secondly does not invalidate the several hundred cases where VAs have occurred after chiroparactic manipulations, mostly those with a rotational component.
Prof Ernst you have no evidence whatsoever that a rotational component is indicated do you? Its a guess isn’t it.
I did not search systematically to answer your silly question, but here is some evidence that happened to be in the SMT file in my office:
Abuquerque et al J Neurosurgery 2011: “…chiropractic manipulation of the cervical spine can produce dissections..”
Miley et al The Neurologist 2008:”Weak to moderately strong evidence exists to support causation between CMT and VAD and associated stroke”
Herzog W J Bodywork Mov Ther 2010: ” The external forces were found to vary greatly among clinicians…”
If you need evidence that rotation is involved, I recommend reading these articles:
Braun et al South Med J 1983
Schellhas et al JAMA 1980
Sherman et al Arch Pathol Lab Med 1987
but there are many, many more.
OK I will help you out a bit, if you ask I’m more than happy to try to help.
here is description of a gonstead neck adjustment.
“One hallmark of the Gonstead Technique is adjustment of the neck with a very specific manouver that is completed with the patient seated. The neck is adjusted in this manner to eliminate the twisting or rotation aspect of the adjusting procedure. In the 1990′s, the Gonstead Technique was recognized throughout the global chiropractic community as one of the safest systems of evaluating and caring for conditions related to the spine.”
I note that many chiropractors post that unsourced quote on their website. How do you think it helps?
FEDUP
You think it’s the same as a doctor not telling a patient about possible side effect of medicine .
In fact this is an insult
First You don’t come under the controled tests they do .
Second , You could ask your doctor and he has to tell you
Third Everyone knows the are possible side effect with any medication
Fourth , The a leaflet in every pack listing such problems and phone number ,warnings Etc Etc
Fith They tell you to ask the Pharmacist if your not sure
You could chose number 4 alone and what would be in that leaflet as medicine has to sight any possible problem and what to do if so . I would love to read that !!
First, the system does not effectively cure musculoskeletal injuries and backache as attested by the statistics.
Second, the doctor tells you there is no effective cure which acts as a nocebo and the treatments they offer you do not work which which plunges you to a deep depression. You believe that this knife permanently lodged in the middle of your back is a life sentence and you will never escape it. You stop going to work, become unproductiveand bed bound and slither on the carpet like a snake unable to sit on a comfy settee from pain and sleeping at night is a torture.
Third, everyone gets to know that medication will only help the pain for a short while while giving you side effects and will not cure your musculoskeletal injury and you start worrying about the state of your digestive system.
Fourth, the list frightens you so much that you stop going to the doctor or take your medication.
Fifth, having lost confidence and faith in the system, you give doctors and medicines a wide berth and try to improve your diet, take up exercise and take up alternative therapies that give you relief, exercise and mind relaxation and your problem more often than not is solved.
martin wrote: “…the system does not effectively cure musculoskeletal injuries and backache as attested by the statistics…having lost confidence and faith in the system, you give doctors and medicines a wide berth and try to improve your diet, take up exercise and take up alternative therapies that give you relief, exercise and mind relaxation and your problem more often than not is solved.”
IOW, you accept the reality of your situation and start learning coping strategies (and, in your case, attempt to enhance them by gambling with the unpredictable placebo effects of alternative therapies).
Chiropractic was more than a placebo because I also had several physical limitations in the movements of my back, neck and shoulders that would not go away by other treatments and have not recurred since.
As to the much maligned placebo effect, dopamine among other chemicals in the brain that are activated in placebos is implicated in the cause and treatment of many conditions including pain as in IBS and PD, etc. It is also found in behavioral genetic models of reward responsiveness and confirmation bias, the tendency to confirm new information based on your beliefs.
In the case of COMPT val1158met polymorphism, the changes in the COMPT gene result in people having either two copies of the methionine (met) allele, two copies of the valine (val) allele, or one copy of each; met/met, val/val or met/val.
It seems that people with two copies of met, the “met/mets,” have three to four times more dopamine available in their prefrontal cortex and six times more likely to respond to placebos and have more pain reduction:
“Armed with this original data, the scientists genotyped blood samples from patients from the earlier study, using a statistical method known as regression analysis to analyze the effects of a person’s genotype and the type of treatment received. “Our regression analysis found that as the copies of met increased, placebo responses increased in a linear fashion, presumably because more dopamine was available,” Hall explains. The findings showed that among the IBS patients who had been in the waitlist treatment arm there was no difference in treatment responses between met/met, val/val and met/val genotypes as determined by the IBS-Symptom Severity Scale and Adequate Relief. Among those in the group that received a placebo administered in a businesslike manner, the met/met genotypes showed a small improvement over their val/val and met/val counterparts.
But, among the individuals who had received placebo treatment from the warm supportive health care providers, there was a striking difference: the “met/mets” demonstrated a six-fold greater improvement in their IBS symptoms relative to the “val/vals.”
“These findings suggest that it is possible that met/met is a genetic marker for the placebo response and val/val is a marker for non-response,” says Hall. “In addition, our findings underscore differences in placebo response based on the patient’s experience of the clinical environment. In the case of the met/met individuals, you can really see the advantage of a positive doctor-patient relationship. Conversely, our findings suggest that the val/val patients are less influenced by placebo treatment and this sheds light on a clinical challenge faced by many health care providers, whose empathic care helps some people, but makes no difference to others.”
“…being able to predict a genetic predisposition for heightened placebo response could potentially have a major impact in reducing the size, cost and duration of clinical trials… a significant step forward in understanding, predicting and controlling the placebo effect and could help lead to revolutionary changes in the way new medicines are developed in the future.”
Gamble it may be but the chances are one in three and the prizes invaluable – until better science is available.
martin wrote: “Chiropractic was more than a placebo because I also had several physical limitations in the movements of my back, neck and shoulders that would not go away by other treatments and have not recurred since…Gamble it may be but the chances are one in three and the prizes invaluable – until better science is available.”
Bearing in mind that most chiropractors work in private practice, and that you required “many sessions” of chiropractic, few people would be able to afford such a gamble. More importantly, though, as I’ve already pointed out, many of those who can afford it are likely to be risking – unwittingly – their time, money, and in some cases lives, by submitting themselves to chiropractic ‘care’. The bottom line is that the current science tells us that chiropractic spinal manipulation is not a recommendable treatment. Indeed, it’s worth remembering what Simon Singh wrote in the conclusion to his 2008 Guardian article which saw him being sued *unsuccessfully* by the British Chiropractic Association:
Quote
“…if spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.”
http://www.guardian.co.uk/commentisfree/2008/apr/19/controversiesinscience-health
…e.g. reports of deaths after chiropractic treatment are apparently about three times the number of deaths from trovafloxacin, an excellent antibiotic abandoned in the U.S. as too dangerous
http://www.sciencebasedmedicine.org/index.php/compare-and-contrast/
Well, I am here and very much well, and I also think that chiropractic is changing; the young lady who attended me was gentle and gave me absolutely no aches as I was expecting to be jolted like Frankestein after the treatment having read all the skeptics’ views on it; all I felt was relief.
As to the gamble I was referring to a gamble of having the met/met gene as opposed to the val/val and val/met gene.
There are many sufferers out there; we need to concentrate on the positives a little bit more…. We have heard all the arguements against it already.
martin wrote; “well, I am here and very much well”
You are very lucky…
http://www.ebm-first.com/chiropractic/risks/1546-deaths-after-chiropractic-a-review-of-published-cases.html
martin wrote: “There are many sufferers out there; we need to concentrate on the positives a little bit more…”
…but not when risks outweigh benefits.
It is a risk patients are willing to take; persistent back ache can seem like a death sentence anyway with the quality of life very much reduced. And as I said, chiro is changing and I was surprised how gentle it was coming from a recently graduated young lady.
And back manipulation is has probably been around for as long as our ancestors got on two legs and decided to walk.
I would rather get mine from a highly educated and highly trained individual rather than if it otherwise went underground.
martin wrote: “It is a risk patients are willing to take; persistent back ache can seem like a death sentence anyway with the quality of life very much reduced.”
We seem to be going round in circles now. Patients can’t take that risk unless they’ve been properly informed, and, as has already been discussed, it would seem that in the majority of cases they are not.
martin wrote: “And as I said, chiro is changing and I was surprised how gentle it was coming from a recently graduated young lady.”
Evidence please, not anecdotes.
martin wrote: “I would rather get mine from a highly educated and highly trained individual rather than if it otherwise went underground.”
Again, as already discussed, with no standardisation in chiropractic it’s difficult for a patient to know what sort of chiropractor they’ll get (i.e. mechanistic or vitalistic, ethical or unethical). Being “highly educated” and “highly trained” is no guarantee that a chiropractor will follow ethical, evidence-based practice.
You are right about one thing; we have come full circle, probably more than once!
I have been enjoying the wild life of Kruger National Park in South Africa and have not always had a mobile signal to respond to Edzards comments on my questions to him. In response to a question from Ben Tinkler, Edzard states; I tend to ask multiple questions and when he “answers” them I multiply them again???
Edzard you raise many issues and when I have asked you to explain your opinion you simply ignore the question and move to something else. In this thread you have called me a quack, then stated I am making “medical claims” on my website, you have poked fun at my education, knowing full well your knowledge of anatomy and physiology is limited. I am still waiting for you to explain why you think I am writing about medicine on my website and not chiropractic. I would also like to know what expertise you think you have to be so opinionated about chiropractic, when all you seem to know is that there are hardly any Randomized Controlled Trials (RCTs), showing chiropractic to be effective intervention and that there is anecdotal evidence that manipulation can cause stroke, as there is also after visits to hairdresser and other everyday activities, even dogs have idiopathic strokes http://www.petwave.com/Dogs/Dog-Health-Center/Brain-Spinal-Cord-Nerve-Disorders/Stroke/Causes.aspx , a similar scenario to humans and dogs dont smoke, the largest predisposing factor for stroke according to the scientists. Your knowledge of chiropractic is why I dont ask you about chiropractic, just as I would not ask a plumber why my computer was not working. I am merely interested in where your opinions come from, rather than trying to change them.
For example, earlier you stated my comments on vaccination were “antivaccination”, I asked you to be specific and even numbered, points 1-5, you had little to say, except in a response to Ben you gave an answer to my point 5; “Why did your definition of Evidence Based Medicine in Trick or treatment leave out “patient values” and “practitioners experience” ? Below is what you said.
“About TRICK OR TREATMENT, the answer is simple: this book was not about EBM in the sense he puts it; it was about the external evidence as it pertains to alt med. This is clearly set out in the book. If we had wanted to write about patients’ preferences and experience, we would have used a different approach and written a different book.”
In my opinion the book is about how “published” evidence, particularly randomized clinical trials (RCTs) pertains to alt med, rather than Sackets model of Evidence Based Medicine (EBM). However in the book you state in the very first chapter that Sacketts model of EBM is the way to evaluate “alt med” . The first chapter is titled “How do you Determine the Truth” and a section is headed “Evidence Based Medicine”. This is where you give your very narrow definition of EBM, which supports the points you want to make in the book, that in your opinion “alt med”, is a “trick” on consumers. Having given your definition of EBM, you state that: “it empowers doctors by providing them with the most reliable information and therefore it benefits the patient by increasing the likelihood they will receive the most appropriate treatment. From a twenty-first century perspective, it seems obvious that medical decisions should be based on evidence, typically from randomized clinical trials, the emergence of EBM marks a turning point in the history of medicine.”
To be consistent with Sacketts model of EMB, you have to include patients values and the experience of practioners as part of the evidence you are using to evaluate alt med, you do not have to “write a different book” jus be accurate to the reference you are using. The problem you have with Sackets EBM model is clear from this thread, you don’t view patient values or practitioner experience as credible evidence. They are two of the pillars Sackett based his EBM model on so what you should have done is referenced Ernst, to support your definition of EBM not David Sackett. For example if one was using Sackets model to assess claims that chiropractic may help infants with colic, they meght say there is little convincing “published evidence” to support any intervention for infants with colic, but arguably chiropractors have done more research than any other group and short of doing nothing a parent not getting any sleep could decide its worth a try, as the anecdotal evidence of experienced practitioners is positive. The Danish government funds chiropractic as an intervention if the colic is diagnosed by a GP. This is an article I have written about chiropractic and colic http://www.chiropracticlive.com/if-your-infant-has-colic-why-not-try-spinal-care-dare-i-say-chiropractic/ and I challenge you to come up with an intervention using your own critera “Beyond reasonable doubt” to offer parents that cures infants with colic? And I will be the first to rec-comment it.
Anyway thats my lot on this thread, you wont have to block me as you did on Twitter to stop me asking questions. I would add I don’t subscribe to “Ernsts Law”, I bear you no ill will and you are perfectly entitled to your opinion , I would even take some of them on board if they reflected what I saw in practice every day (experience) they don’t.
Richard Lanigan wrote: “To be consistent with Sacketts model of EMB, you have to include patients values and the experience of practioners as part of the evidence you are using to evaluate alt med, you do not have to “write a different book” jus be accurate to the reference you are using. The problem you have with Sackets EBM model is clear from this thread, you don’t view patient values or practitioner experience as credible evidence.”
Richard, your goalpost shifting exercise has been attempted previously by Alan Breen, Professor of Musculoskeletal Health at the Anglo European College of Chiropractic, and was countered by some sound, critical comment:
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“…Breen seems to be moving towards a privileging of the experiences of a small subset of medical professionals – chiropractors and associated practitioners – and he seems to be advocating this privileging at the expense of numerous other stakeholders: from patients to researchers. Evidence-based medicine is certainly not perfect – and there are important areas in which it should be improved, supplemented or superseded. However, compared to Breen’s approach – an odd kind of chiropractic-centric obligarchy – evidence-based medicine is a much more promising approach.”
http://translucentscience.wordpress.com/2009/06/27/alan-breen-in-praise-of-chiropractic-and-democracy/
“The Journal of Health Services Research and Policy has just published a ‘perspective’ piece by Professor Alan Breen of the Anglo-European College of Chiropractic in which he, unsurprisingly, praises chiropractic… [Breen concludes] that, “strong ontological commitment to only part of the knowledge base seems often to be the stance taken to contest the scientific basis of chiropractic” at the end of an argument where he neglects to mention any trials that test the efficacy of chiropractic for any condition. Moreover, the article does not cite a single negative study or review. Instead, politicians and committees are the preferred source of authority. Again, a preference for one side of the knowledge base is seen in the author’s focus on risks that are not balanced against benefits. Having had a look for the evidence, it appears to me that in an evidence-based biopsychosocial model for the treatment of musculoskeletal complaints: Chiropractic is, at best, unnecessary.”
http://apgaylard.wordpress.com/2009/07/03/in-praise-of-chiropractic/
With regard to chiropractic for infantile colic, it has already been pointed out that chiropractic research methods use dishonest selectivity:
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“What [the British Chiropractic Association] don’t do is mention any of the papers that contradict their claims. They cite Sackett et al. (1996) as their criterion for what constitutes evidence. That paper says “Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence”. That means all the evidence. So why, for example, is there no mention of Olafsdottir et al. (2001), “Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation”. That is one of the few really good papers in the area. It compared chiropractic treatment of babies for colic with placebo treatment (the nurse just held the baby for 10 minutes (the time the chiropractor took). The conclusion was…Chiropractic spinal manipulation is no more effective than placebo in the treatment of infantile colic. This study emphasises the need for placebo controlled and blinded studies when investigating alternative methods to treat unpredictable conditions such as infantile colic.”
http://www.dcscience.net/?p=1775
In other words, chiropractors don’t seem to have a problem with ignoring unfavourable evidence: http://holfordwatch.info/2009/06/18/british-chiropractic-association-bca-demonstrate-what-evidence-based-medicine-isnt/
So, in summary, Sackett doesn’t say that clinical expertise and patient values are a substitute for science, but that they are part of the mix. Many chiropractors, however, seem content to add their own prejudices into the mix at the expense of their patients’ time, money, and – in some cases – lives.
Blue Wode, I was thinking of you in Africa not for your views on chiropractic, but your efforts to make people aware of the threat to the Rhino and I have some nice pictures of a few Rhinos I met in the wild.
I have never said Sackett saw the experience of the practitioner or patient values as a substitute for science. Sackett based his EBM on “three pillars”, in other words the ability of an experienced practitioner to access the published evidence and patients values when making a decision about treatment, all three have a symbiotic relationship. Just as Edzard and you accuse CAM practitioners of making decisions in isolation, it is not that different from the way Edzard and you arrive at your conclusions. In the article I wrote about colic, i dont describe chiropractic as a cure for colic, I say that in my experience, for the pysiological reasons outlined what I do may help and is worth trying. You may disagree based on studies which show that chiropractic treatment was no better than a placebo. If an infant is in a study as having colic and stops crying when picked up by the parent (the placebo effect), that child did not have colic, and would not be the first trial in history that used unsuitable subjects to make a point. All I am asking Edzard is why he he implied he was using Sacketts EBM model to evaluate alt med when he and Simon were only looking at published research and it was disingenuous to reference Sackett. I very rarely use chiropractic research studies to back up something i say because you cant extrapolate much from them because the sample groups are usually quiet small. I dont see a lack of published papers as a reflection on my ability I am not a researcher and if I was a researcher I would be a bloody good one and do original research. Some years ago I did an infomercial for Scania about sitting while driving they were so impressed with me, they offered to put up £50,000 into researching what I was talking about, I but them in touch with the BCA head office and Scania Marketing people soon lost interest, such is life. Research needs money and to raise money to do original research you need researchers with charisma which is a bit of an oxymoron.
As for Alan Breen’s views, like Edzard Ernst he is just another academic with too much time on their hands, I sat on the AECC management committee with him for two years and my time on the GCC. Then I am biased Alan was one of those who voted to have me removed from the chiropractic regulatory body, as you know its an honor I wear with pride. I guess when the expression those who cant do, teach, they were referring to clinicians like them.
Richard Lanigan wrote: “I was thinking of you in Africa not for your views on chiropractic, but your efforts to make people aware of the threat to the Rhino”
Thank you. It’s good to know that I’ve helped to raise awareness of the problem, albeit it in a very small way.
Richard Lanigan wrote: “Sackett based his EBM on “three pillars”, in other words the ability of an experienced practitioner to access the published evidence and patients values when making a decision about treatment, all three have a symbiotic relationship”
It appears that you haven’t grasped what that really means. The following paragraph was written by Andy Lewis of the Quackometer (I don’t have the link, but kept a copy of the text – it may even have been addressed to you):
Quote
“Good evidence making comes from using External Evidence AND Clinical Expertise AND Patient Values, not External Evidence OR Clinical Expertise AND/OR Patient Values. Are you advocating that your clinical ‘experience’ (which can often equate to simple prejudice) and patient wishes should be able to ignore and trump the evidence, no matter what the evidence says?”
Richard Lanigan wrote: “All I am asking Edzard is why he he implied he was using Sacketts EBM model to evaluate alt med when he and Simon were only looking at published research and it was disingenuous to reference Sackett.”
Prof Ernst and Simon Singh did not just look at published research. Chapter 6 of Trick or Treatment?, entitled ‘Does the Truth Matter?’, addresses fully the problems of clinical experience and patient choice (the other two of Sackett’s “three pillars”) in relation to CAM.
Richard Lanigan wrote: “In the article I wrote about colic, i dont describe chiropractic as a cure for colic, I say that in my experience, for the pysiological reasons outlined what I do may help and is worth trying. You may disagree based on studies which show that chiropractic treatment was no better than a placebo.”
I disagree not just because it appears to be no better than a placebo, but because in the absence of good safety data a responsible risk/benefit assessment would contraindicate chiropractic treatment:
http://www.ebm-first.com/chiropractic/safe-for-children.html
There is yet another reason discovered why the trials and anecdotes and experiences of patients and therapists may vary:
If we analyse the findings by the Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School (HMS) on the pain reduction capabilities of the placebo effect in general:
“It was shown that COMPT val1158met polymorphism, the changes in the COMPT gene which is involved in the dopamine pathway, result in people having either two copies of the methionine (met) allele, two copies of the valine (val) allele, or one copy of each; met/met, val/val or met/val.
Among the IBS patients who had been in the waitlist treatment arm there was no difference in treatment responses between met/met, val/val and met/val genotypes of as determined by the IBS-Symptom Severity Scale and Adequate Relief.
Among those in the group that received a placebo administered in a business like manner, the met/met genotypes showed A SMALL improvement over their val/val and met/val counterparts.
But, among the individuals who had received placebo treatment from the warm supportive health care providers, there was a striking difference: the “met/mets” demonstrated a SIX-FOLD greater improvement in their IBS symptoms relative to the “val/vals.”
Having been newly discovered, we have little knowledge of the demographic distribution of the COMPT val1158met polymorphism.
I would hypothesise that the kind of people who volunteer for clinical trials may be the val/val and met/val types and the people who go for alternative therapies are the believers, i.e. the met/met variants.who also benefit from going to the church, etc.
Also, most clinical trials are likely to fall in the second category where the placebo effect is taking place in a “business like manner”; where the patient is feeling like a guinea pig and getting little benefit even if they were met/met.
Whereas in a small practice, with “the warm supportive health care provider” on a one to one basis with the focus on the patient alone, it is possible to produce up to six fold improvement in their pain symptoms as in the third arm of the trial. Again, the demographics is unknown as the what proportion of the population and which regions would benefit most.
Apart from the other known weaknesses of trials, these new findings could explain the discrepancy between the trials and the private experiences and anecdotes of patients and therapists alike.
This variable alone makes a strong case for people who benefit from CAM therapies to have their pain reduction and other benefits to be delivered separately by a “warm supportive care worker” in a psychologically inducive setting as the personal approach is increasingly missing from the system where it is potluck when, where and which healthcare provider will be allocated to you including your GP.
Woul the proffesor comment on germany where the majority of orthopedic doctors deliver spinal manipulation. And the diagnosis of blockade and hexenschuss is a common medical diagnosis