Even though I have not yet posted a single article on this subject, it already proved to be a most controversial subject in the comments section. A new analysis of the evidence has just been published, and, in view of the news just out of a Royal Charter for the UK College of Chiropractors, it is time to dedicate some real attention to this important issue.
The analysis comes in the form of a systematic review authored by an international team of chiropractors (we should not fear therefore that the authors have an “anti-chiro bias”). Their declared aim was “to determine whether conclusive evidence of a strong association [between neck manipulation and vascular accidents] exists”. The authors make it clear that they only considered case-control studies and omitted all other articles.
They found 4 such publications all of which had methodological limitations. Two studies were of acceptable quality, and one of these studies seemed to show an association between neck manipulation and stroke, while the other one did not. The authors’ conclusion is ambivalent: “Conclusive evidence is lacking for a strong association between neck manipulation and stroke, but it is also lacking for no association”.
The 4 case-control studies, their strength and weaknesses are, of course, well-known and have been discussed several times before. It was also known that the totality of these data fail to provide a clear picture. I would therefore argue that, in such a situation, we need to include further evidence in an attempt to advance the discussion.
Generally speaking, whenever we assess therapeutic safety, we must not ignore case-reports. One might be next to meaningless but collectively they can provide strong indicators of risk. In drug research, for instance, they send invaluable signals about potential problems and many drugs have been withdrawn from the market purely on the basis of case-reports. If we include case-reports in an analysis of the risks of neck manipulations, the evidence generated by the existing case-control studies appears in a very different light. There are virtually hundreds of cases where neck manipulations have seriously injured patients, and many have suffered permanent neurological deficits or worse. Whenever causation is validated by experts who are not chiropractors and thus not burdened with a professional bias, investigators find that most of the criteria for a causal relationship are fulfilled.
While the omission of case-reports in the new review is regrettable, I find many of the staements of the authors helpful and commendable, particularly considering that they are chiropractors. They seem to be aware that, when there is genuine uncertainty, we ought to err on the safe side [the precautionary principle]. Crucially, they comment on the practical implications of our existing knowledge: “Considering this uncertainty, informed consent is warranted for cervical spinal manipulative therapy that advises patients of a possible increase in the risk of a rare form of stroke…” A little later, in their discussion they write: “As the possibility of an association between cervical spinal manipulative therapy and vascular accidents cannot be ruled out, practitioners of cervical spinal manipulative therapy are obliged to take all reasonable steps that aim to minimise the potential risk of stroke. There is evidence that cervical rotation places greater stresses on vertebral arteries than other movements such as lateral flexion, and so it would seem wise to avoid techniques that involve full rotation of the head.”
At this point it is, I think, important to note that UK chiropractors tend not to obtain informed consent from their patients. This is, of course, a grave breach of medical ethics. It becomes even graver, when we consider that the GCC seems to do nothing about it, even though it has been known for many years.
Is this profession really worthy of a Royal Charter? This and the other question raised here require some serious consideration and discussion which, no doubt, will follow this short post.
No, this is not a profession worthy of a Royal Charter, IMO.
The authors of the study advise “practitioners of cervical spinal manipulative therapy are obliged to take all reasonable steps that aim to minimise the potential risk of stroke”, but we can hardly expect the hundreds of vitalistic, subluxation-based chiropractors in the UK to pay heed to that since the neck is usually the main focus for their quackery. And there’s also this to consider with regard to back pain patients:
“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.
Yet, apparently the GCC doesn’t see the above as a public health concern:
As for the College of Chiropractors itself, it’s worth noting that it administers the CPiRLS [Chiropractic Patient Incident Reporting and Learning System] which monitors adverse events …
…although so far it’s been pretty useless:
But what I’d really like to know is how the College’s petition for a Royal Charter was successful. Who made up the “eminent Advisory Board of parliamentarians, peers and senior officials” who helped bring it to fruition? See page 11 here http://tinyurl.com/cmfjabk
Did these people not understand the following?
A body applying for a Royal Charter is normally expected to meet a number of criteria, one of which is that it should comprise members of a unique profession. However, the only unique aspect of chiropractic would appear to be its pseudoscientific underpinnings. It has been said that without their subluxation theory, chiropractors are reduced to manipulative therapists practicing a very limited modality shared by osteopaths, physiatrists, sports trainers, physical therapists and others: That without subluxation theory, chiropractic’s claim that it is a unique and comprehensive ‘alternative’ to standard medicine is lost. Furthermore, a body applying for a Royal Charter is expected to have 5,000 or more members. In the UK, there are currently around 3,000 chiropractors.
As for the College’s official announcement of its Royal Charter, it claims that it is:
“…an academic, professional membership body, established along the lines of the Medical Royal Colleges, which over the past 13 years has sought to ensure quality, safety and excellence are at the forefront of chiropractic practice in the public interest… NHS funding for chiropractic treatment is now emerging region by region under the Department of Health’s new commissioning arrangements.”
That is plain puffery. Note that the NHS doesn’t endorse chiropractic…
…and that many Primary Care Organisations are refusing to fund NICE’s recommendation of spinal manipulation for back pain because of the controversy surrounding it:
Most outrageous of all is its claim “…a Royal Charter signals permanence and stability”. It is no secret that chiropractic has long been a divided profession, suffering from serious in-fighting on a universal scale, and lacking any sort of acceptable standardisation. Indeed, I’m sure that the College would rather forget that they gave Emotional Freedom Technique CPD status:
And I’m sure it would also not like having some of its seminars on pregnancy and paediatric theory read by the scientific medical community:
Nor do I think that the veterinary community would be too impressed with its Animal Faculty:
“Many animal owners have found dramatic proof of the efficacy of this healing art which helps the body restore itself to proper health without the use of drugs or surgery. In the UK, the main animals that are presented for treatment are horses, dogs and cats. Animals may require treatment after a trauma, following injuries sustained during athletic competitions, through playing together or through conformation of the animal.”
For the enlightenment of readers, the evidence for chiropractic for animals is almost non-existent:
All in all, it’s not deserving of being a Royal College. A right royal House of Cards would be more fitting.
I fully agree that it is entirely unacceptable for a clinician not to disclose risk, real, suspected or potential. I also think that the profession (of which I am no longer a member because I feel the GCC does not enforce standards adequately) will have made progress on the sad state of affairs reported by Langworthy in the research mentioned (2005). This, largely due to sites like these.
@ Stefaan Vossen
What standards do you feel that the GCC do not enforce? Also is it easier or harder to influence these “standards” when inside or outside the profession?
Stefaan Vossen wrote: “I…think that the profession…will have made progress on the sad state of affairs reported by Langworthy in the research mentioned (2005).”
Sadly, there’s a distinct possibility that there’s been no progress at all…
“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.”
Ref. Edzard Ernst, The Guardian Science Blog (12th July 2011)
Please do not refer to chiropractic as quackery. We have proved chiropractic is at least affective for numerous musculoskeletal conditions. At no point have chiropractors recommended to the therapeutic use of mercury.
Next you’ll be telling us that the BCS won an outstanding victory in the court case against Simon Singh when he exposed the quackery in chiropractic, and that the ASA were wrong whong when they had some 45% of practices in the UK investigation and the web-site pulling never happened.
….numerous musculoskeletal conditions….??? ….. numerous??? Are you sure? Can you provide a list?
Jesgol wrote: “Please do not refer to chiropractic as quackery.”
Essentially, chiropractic is quackery. It is a fact that, after nearly 120 years, chiropractic has still not been able to prove its basic tenet, the chiropractic ‘subluxation’. In spite of that, between 70%-90% of chiropractors haven’t denounced it, and quite a few of those who make up the remaining group are likely to continue to cling to it, albeit covertly.
With regard to chiropractic quackery in the UK, the Alliance of UK Chiropractors (AUKC), which has a combined membership of several hundred chiropractors, most of whom are existing members of either the McTimoney Chiropractic Association (MCA), the United Chiropractic Association (UCA), or the Scottish Chiropractic Association (SCA), has formally adopted the International Chiropractors Association’s (ICA) ‘Best Practices’ documentation which, among other policies, supports 27 indications for chiropractic radiography including (mythical) spinal subluxation, birth trauma, facial pain, skin diseases, organ dysfunction, eye and vision problems, and hearing disorders, and recommends a basic care plan for simple uncomplicated axial pain (neck pain, back pain, etc) consisting of 25 visits over 8 weeks – with the presence of ‘complicating factors’ (including family/relationship stress, lower wage employment, and wearing high-heeled shoes) warranting a recommended additional 12-visit blocks of care. See:
That’s not a very reassuring picture when you consider that the profession in the UK has been regulated by statute for the last 11 years.
Jesgol wrote: “At no point have chiropractors recommended to the therapeutic use of mercury.”
What are you getting at? Historical times when medicine was in its infancy? The mercury-based preservative ‘thiomersal’ which was *formerly* used in childhood vaccines? Please expand on the point you are trying to make.
I would be interested to know where you got the 70-90% of chiropractors haven’t denounced the subluxation. I am a chiropractor and I have denounced it along with many others. If you are going to throw numbers around please provide a source.
There are many chiropractors, that I know, who are providing evidence based treatment for their patients. We maybe the minority at the moment, however with Universities teaching evidence based chiropractic, this should increase.
Please don’t group all chiropractors amongst the ones who do practice quackery.
Peter Chapman wrote: “I would be interested to know where you got the 70-90% of chiropractors haven’t denounced the subluxation. I am a chiropractor and I have denounced it along with many others. If you are going to throw numbers around please provide a source.”
Here you go:
89.8% of (USA) chiropractors feel that spinal manipulation should not be limited to musculoskeletal conditions. Ref: McDonald W, Durkin K, Iseman S, et al. How Chiropractors Think and Practice. Ada: Institute for Social Research, Ohio University, 2003.
The World Federation of Chiropractic (an association of chiropractic organisations in 85 countries) 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. [Ref. 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:
Peter Chapman wrote: “There are many chiropractors, that I know, who are providing evidence based treatment for their patients. We maybe the minority at the moment, however with Universities teaching evidence based chiropractic, this should increase.”
How does what they teach differ from physiotherapy?
Peter Chapman wrote: “Please don’t group all chiropractors amongst the ones who do practice quackery.”
That’s currently not possible. As asked previously on this blog (and not yet answered) how would you find a reputable chiropractor? For example, how would a member of the public distinguish between a reputable registered chiropractor and a disreputable registered chiropractor when consulting the UK General Chiropractic Council’s register?
Could the chiropractic community please answer this very pertinent question:
How would a member of the public distinguish between a reputable registered chiropractor and a disreputable registered chiropractor when consulting the UK General Chiropractic Council’s register?
Sorry about the delay in responding. To find an evidence based chiropractor is fairly simple. If a chiropractor did the following I would not go and see them.
1. If they suggest that x-rays are needed before even examining you or taking a history.
2. Tell you that you have subluxations and do not give you a proper diagnosis
3. Want to put you on an excessive treatment plan. This is tricky as it depends on your diagnosis but if they are wanting to put you on more than 4 weeks treament/payment plan then that is not good .
4. If the initial consultation is less than 30 minutes long then a proper history and examination is not possible if treatment is also provided on that visit.
5. If regular treatment times are less than 15 minutes then a proper assessment and treatment is also not possible.
Check with your countries code of conduct and see if they are following it. For Australia it can be found at http://www.chiropracticboard.gov.au/Codes-guidelines/Code-of-conduct.aspx
I’m wondering on going Chiropractor. Have had neck and head pain for three weeks. Pain killers just make me feel petty bad. Do you think that can go to Chiropractor? I’m of course very worried about risks of neck manipulation so do you think it’s safe? There is a new study about topic please, see link), could you comment it too? It seems to say that your reviews are not very well thought.
Thank you in advance,
BM: I am sorry but this blog is not about giving medical advice. I hope you understand.
I see. Could you give some comments about this study? It seems to say that Chiropractic could be safe option for me too.
Thank you for your reply,
I cannot tell what is safe for you – that would be medical advice which I am reluctant to provide. If you were a cadaver treated in exactly the way these researchers did, I might assume that the intervention is safe. Luckily you are not.
The origin of the term ‘quackery’ comes from a time when people would recommend the therapeutic application of mercury for certain ailments. It is derived from the word quicksilver. It is inaccurate in describing chiropractic as no chiropractic premise rests upon imbibing mercury. But it’s interesting you should mention Thiomersal, which actually isn’t the most prevalent source of mercury intoxication as a 2009 european commission report states, rather amalgam fillings. But lets not put Prof. Ernst or Mr Singh, sorry, Blue Wode on a soapbox about holistic dentistry!
To qualify the numerous conditions that chiropractic is effective for, I will refer to the Bronfort report 2010.
acute, subacute, and chronic low back pain;
migraine and cervicogenic headache;
a number of upper and lower extremity joint conditions.
acute/subacute neck pain.
(in association with rehabilitation)
acute whiplash associated disorders;
chronic neck pain.
This is what we know to date, but I dare not say we know everything.
Bronfort G, Haas M, Evans R, Leininger B and Triano J. (2010). Effectiveness of manual therapies: the UK evidence report . Chiropractic & Osteopathy. 18 (3).
Jesgol wrote: “The origin of the term ‘quackery’ comes from a time when people would recommend the therapeutic application of mercury for certain ailments. It is derived from the word quicksilver. It is inaccurate in describing chiropractic as no chiropractic premise rests upon imbibing mercury.”
Chiropractors may not have recommended the therapeutic use of mercury, but the modern interpretation of the word quackery – the promotion of unsubstantiated methods that lack a scientifically plausible rationale – still applies to them in generous measure.
I think you might be mistaken thinking that Blue Wode is Simon Singh. And you are certainly wrong, if you believe that the Bonford report was a piece of reliable evidence. It was a lame attempt of a chiropractic white-wash, payed for by the GCC and executed by chiropractors who had a very clear interest in producing positive results. Moreover, it explicidly excluded the quality of the data from its considerations; this alone renders it not worth the paper it was printed on.
Sorry, but you are twice wrong here.
What specific treatments does the Bronfort report provide evidence for?
what article would you accept Prof. Ernst?
Internationally, Cochrane Reviews are accepted to be objective, fair, reliable and transparent; unsurprisingly, i also accept my own systematic reviews. The point is a review has to be systematic which includes a consideration of the quality of the primary data. I would add, they ought to be written by experts who are free of conflicts of interest. On these criteria, the Bonfort report scores very low indeed.
So cochrane reviews and your studies are acceptable. Rather than looking at chiropractic care in isolation, how do other professions compare when using this criteria as the only acceptable level of evidence in the treatment of musculoskeletal conditions? What are the conclusions of your systematic reviews for PT interventions for low back pain, neck pain, headache, migraine etc? What do the cochrane reviews conclude?
Ok I’ll play by your rules.
“A 2011 Cochrane review found strong evidence that there is no clinically meaningful difference between spinal manipulation and other treatments for reducing pain and improving function for chronic low back pain.”
“A 2010 Cochrane review found low evidence that manipulation was more effective than a control for neck pain, and moderate evidence that cervical manipulation and mobilisation produced similar effects on pain, function and patient satisfaction.”
“A 2004 Cochrane review found evidence that suggests spinal manipulation may be effective for migraine, tension headache and cervicogenic headache.”
Do you interpret that as chiropractic is ineffective, or equally as good as other interventions?
Thanks Allan: I believe that the bronfort report is assessing chiropractic treatment. The modern chiropractic model is centred around restoring function to dysfunctional joints. The physiology of this application is based purely on sound universally agreed human biology – the active, passive and neurological control of articulating structures. What is also universally understood is that joints do not exist in isolation, and contribute to biomechanics of human movement. The basic example is how foot function contributes to dynamic stabilisation of the spine during the gait cycle, and vice versa. We understand now that proprioception is a global rather than local system, and by affecting (restoring Proprioceptive afferents) to one part of the body we can affect distal and proximal structures. A classic example is the Systematic review by Herd (2008) of cervical mobilisation for patients presenting with lateral epicondylitis “resulted in significantly better pain relief and functional improvements in both the short and long-term.”
But I must remind you that first and fore-most modern chiropractors treat people and not symptoms. It is wrong to assume that every patient who walks into my clinic needs spinal manipulative therapy. This is why we undergo rigorous training in many disciplines to identify the most appropriate course of management for that patient at that time. I always examine the patient to determine if they are a candidate for my care, and can precheck all my adjustments before hand to predict therapeutic outcome. Patients usually leave my clinic functionally stronger than when they came in, or with a letter of referral. I’m happy to show anyone who is willing to observe and they can test my rationale and methods. I want to know if I am wrong so I can change and improve.
Bonfort et al did not assess chiropractic treatments but all types of manual therapy, including massage.
The Cochrane reviews show that SM is as good or as bad as other interventions for chronic back pain. For neck pain and headaches, there is no strong evidence, as you rightly point out.
Do you think ONE indication means “numerous” – even if we counted the other 2, it would not be NUMEROUS. So were you trying to mislead us or not?
Here’s an interesting observation on the Bronfort report (made by Alan Henness) that’s well worth highlighting:
“…why was the Hancock et al. study (which has nothing to do with chiropractic, remember) ever considered by Bronfort? The GCC has made it abundantly clear that Hancock et al. has nothing whatsoever to do with chiropractic. Even if Bronfort was not aware of this at the time, you’d have thought someone at the GCC would have read it and noticed this irrelevant Hancock study and either asked Bronfort to remove it or issue an amendment to it. Neither has happened…
…if the Hancock study is to be removed from Bronfort because it had nothing to do with chiropractic manipulation, then we must also remove all the other papers that Bronfort cited that were not explicitly to do with chiropractic and chiropractic manipulation…
…Chiropractors can’t have it both ways: chiropractors can’t claim to be unique amongst the manual therapists because of their techniques, yet claim any evidence for their particular ‘art’ from the studies that were not about chiropractic manipulations. The GCC has made this perfectly clear…
…So, the GCC can’t maintain that Hancock is irrelevant because it’s not about chiropractic manipulations, yet allow their prized Bronfort Report off the hook when it cites trials mainly not about chiropractic. Once all those non-chiropractic manipulations have been removed from the Bronfort Report, what’s left? Not a jot.”
That’s a pretty stunning GCC own goal.
No. The majority of studies Bronfort et al. looked at were for an unspecified ‘manual therapy’ with others for massage, osteopathy and exercise. Now, chiros may well do more than just back-cracking, but Bronfort et al. certainly does not substantiate chiropractic manipulations. Anyway, don’t chiros like to think of themselves as a distinct ‘primary healthcare profession’? Is Bronfort et al. (written by chiros, of course) the best they can come up with?
Good question, Alan. I am afraid they can and do produce much, much more: misleading claim, bogus treatments and other nonsense.And this exchange is a perfect example.
No it says right there that manipulation may be effective for migraine, tension headache and cervicogenic headache. How did you interpret that to mean it’s not effective for those conditions? It’s not misleading at all! Numerous is numerous. It means many. Lots. Several. There are numerous musculoskeletal disorders. Chiropractic is effective for numerous of those. Why wouldn’t it be? It’s like saying nutritionists only treat hunger, which is technically true but a complete misunderstanding of malnutrition.
There’s nothing misleading about what I’m saying. I’m simply stating what is current knowledge – that there are a number of conditions patients present with that receive benefit because of chiropractic intervention. We’ve systematically reviewed those conditions in comparison with a different intervention and found that in this case they are equally effective. Have we finished? no. So we have to keep going until we find that either chiropractic is good for nothing, in which case the profession should be disbanded like the alchemists and the exorcists were, or that chiropractic has benefit to society and should be considered a reputable profession. So far it has been shown to be the latter.
“…may be effective…” means just that; it does not mean it is effective; it means there is no strong evidence.
If you don’t realise that your statements are misleading, I cannot help you. Dream on!
I’m sorry but if you continue to insinuate that I am incapable of presenting anything other than misleading claims, when I am being perfectly reasonable in light of propagating this conversation, then you have no respect for anyone else’s perspective and are in danger of being labelled a dogmatist. We, as a profession, are ready to listen to what you have to say, but keep the snide remarks out of it!
Alan thank you for your observation. It is a good point that in his report, Bronfort did not substantiate what is deemed a chiropractic treatment. Probably for the reason that he was substantiating manual therapy – the umbrella under which Chiropractic is classified – and not chiropractic in itself. That would be to compare chiropractic and osteopathy against one another, when they have many similarities. Chiropractors tend towards a unique identity in the same way cricketers are not baseball players, yet both are considered bat sports – similar, yet distinctly different. while you’d be correct in presuming that both baseball and cricket involve hitting a ball with a wooden bat, you’d be wrong in presuming that that is all they do.
Bronfort’s report was, following this analogy, comparing the athleticism of different sports players with different events. Spinal manipulation (bat sportsmen and women) were good at acute, subacute and chronic low back pain (lets say walking, jogging and running); migraine, cervicogenic headache and cervicogenic dizziness (hopping skipping and jumping); several extremity joint conditions (track events). Thoracic manipulation/mobilisation (cricket fielders and baseball fieldsmen) are good at acute/subacute neck pain (cross country and sprinting). Cervical manipulation/mobilization alone (bowlers and pitchers only) were inconclusive for neck pain of any duration (cross country, sprinting and marathons) and manipulation/mobilization is inconclusive for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults (long jump, high jump, shot put etc.) It then goes on to say that massage (lets compare this with tennis players) are also good at treating chronic low back pain and chronic neck pain (jogging and marathons) but inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome (jumping sports and swimming).
From this one could deduce that when picking an individual to perform a particular event like Marathon running, you wouldn’t pick a bowler and you’d be better off with a tennis player or a fielder. In the same way, if you had subacute neck pain you’d be looking for a manual therapist who is proficient in manipulation/mobilisation (not limited to cervical man/mob) and massage. A chiropractor or osteopath would be an apt choice of health care provider for this task.
As for your comment on “written by chiros, of course”. Who else is going to do our research for us? Do psychologists research surgical procedures? Or car mechanics conduct financial audit? Who would you like to carry out the research? It’s certainly not going to be the pharmaceutical industry! I think chiropractic has done bloody well with the limited resources it has and I thank those dedicated individuals who commit their time and efforts so that the rest of us have something we can put our name on.
No. When Brontfort’s criterion was to find the evidence to substantiate claims being made by chiropractors about the treatment chiropractors were providing, it’s utterly misleading (and intellectually dishonest) to include the results from trials of treatments chiropractors don’t provide.
As for who does the research, the onus is clearly on chiros to justify their own existence. There seem to be very few studies that are actually done to the highest standards, though, and we certainly should not accept the results of any single study as being adequate. That’s where systematic reviews and meta-analyses, if done properly and independently, can help.
As Edzard has already pointed out, Bronfort et al. was not a systematic review and was very poor indeed and I refer you back to what he said about the Cochrane and other independent reviews of the evidence for chiropractic.
An independent review is not independent research. It examines our current evidence of a particular field of research. Again, that would by synonymous with orthopaedic specialists taking it upon themselves to conduct a randomised controlled trial of chiropractic treatment for LBP. manipulation is not their field, so how can you expect anyone but chiropracors to conduct chiropractic research? you’re still going to profess that its not independent. you know you’re not being fair here to be comfortable when the pharmaceutical industry conducts its own research and yet chiropractors are not allowed to conduct their own research. Am I wrong? is that not what you are saying?
Lets apply your standards of review to therapeutic ultrasound for ankle sprains, usually performed by physiotherapists.
van den Bekerom el al. (2011) published a Cochrane summary stating “The main results were from the review of the five placebo-controlled trials (sham ultrasound). These found that ultrasound therapy does not seem to enhance recovery or help to reduce pain and swelling after an ankle sprain, or improve the ability to stand on the affected foot and ankle.” Now, from that, one can only assume there was research of significant quality to justify the outcome of Cochrane review. But that does not mean physiotherapists are ineffective at treating ankle sprains. And I don’t see a marching band condemning the use of therapeutic ultrasound.
We were taught about therapeutic ultrasound at university, but I didn’t find it had favourable clinical outcomes for my patients, so I don’t use it. I do find manipulation and mobilisation produces favourable clinical outcomes, especially when used with precision and skill, so I use it. If I thought surgery was more effective I would have become a surgeon – but it’s less so. So manual therapy it was, and the best in the business, in my opinion, are chiropractors.
I will agree with you that some chiropractors make outlandish claims about what they are capable of achieving. I think their motive is more financial than empathic – such is the world we live in. I ask of you any profession that doesn’t. But you can’t throw the baby out with the bath water. There are good helpful chiropractors who do good work, and thankfully they are becoming the majority in Europe. I think the Singh case was very important as it gave chiropractic the metaphorical kick up the arse it needed. Now we are seeing more effort towards research council through the ECU; Chiropractic has received CEN status (Comité European de Normalisation) to homogenise the standard of chiropractic; standards of chiropractic education are higher than ever; research positions are opening up throughout Europe; chiropractic had a great presence at the London Olympic Games; chiropractors are heads of medical staff at world renowned football clubs; chiropractic is prevalent in northern european hospitals; and people are becoming more and more aware of their own health and the alternatives to drugs and surgery.
I have, in previous posts, presented the cochrane reviews for chiropractic to this date. There will be more as our research improves and more effort is made to provide the level of evidence you are happy with. I highly suggest we organise an event to observe and discuss chiropractic from both sides of the coin. I think that would be highly productive.
Yes, you’re wrong. That’s not what I said.
The onus is on them to do good research. There has been very little of that (and a plethora of bad research) and even then, when the better studies are reviewed independently, they show that the evidence for chiro doesn’t match the claims made for it by chiros. Even the highly selective Bronfort et al. managed that.
Can you say specifically what chiros – in particular the ECU, since you mentioned them – are doing in the way of robust research?
(BTW, most of the rest of your post (CEN status, Olympics, prevalence, etc) is irrelevant to whether or not there is good evidence for chiropractic.)
Jesgol wrote: “I will agree with you that some chiropractors make outlandish claims about what they are capable of achieving. I think their motive is more financial than empathic…”
“Some” chiropractors? Around 70% of UK chiropractors, and around 90% of US chiropractors, buy into traditional chiropractic belief.
Jesgol wrote: “I think the Singh case was very important as it gave chiropractic the metaphorical kick up the arse it needed…”
Apparently it’s been short-lived. Here’s something that Simon Singh wrote at the beginning of this year:
“After the British Chiropractic Association lost its libel action against me, there seemed to be a genuine effort to create a coherent identity that was compatible with the best available evidence. However, the more radical elements in the profession seemed to kick up a fuss, and I suspect that we are back to square one with chiropractors making all sorts of weird claims and a regulator that is unable or unwilling to take control.”
For background to the more radical elements in the profession, see my second comment here:
I’ll be there in case such an event happens – I have personally organised 14 annual conferences for CAM researchers in Exeter; I thus feel I have done my share of conference organising, bridge-building etc.
Professor Ernst wrote: “I’ll be there in case such an event happens – I have personally organised during 14 consecutive years conferences for CAM researchers in Exeter; I thus feel I have done my share of conference organising, bridge-building etc.”
I think it is important for readers to be made aware that the General Chiropractic Council (GCC) claimed, in 2004, that Professor Ernst “…refuses to engage in any meaningful dialogue with the UK chiropractic profession.”
(That link is now dead, presumably having been de-activated after the GCC lost the ‘promoting the profession’ aspect of its remit three or four years ago.)
Nevertheless, just over a year after the GCC’s statement, Professor Ernst attended one of the GCC’s meetings, and the following is what the GCC chose to write about his visit in its open minutes of that meeting:
Presentation by and discussion with Professor Ernst
A copy of Professor Ernst’s presentation is attached as Appendix A to these Minutes. Questions to Professor Ernst in the subsequent debate included:
• Are you familiar with the work of Herzog et al regarding the physical characteristics of cervical spine manipulation and its effect on the vertebral artery?
• How do you rationalise your view of the chiropractic profession as responsible for most serious adverse affects when osteopaths, some physiotherapists and other professionals also engage on a global basis in manipulation of the cervical spine?
• Why do you say that osteopaths use mobilisation, which is inherently safer and chiropractors only manipulate, which carries more risk?
• Where is your evidence of “serious adverse events, such as stroke (sometimes fatal) are regularly reported”?
What’s disgraceful about the above is that Appendix A, and the minutes of the ensuing debate, seem to be for chiropractors’ eyes only as they were *never published online* despite the GCC priding itself on being a transparent regulatory body…
Alan: So you’re not going to accept the Cochrane reviews stated previously as good evidence?
I’m wondering still getting treated somewhere. Neck pain is like hell now. Alcohol feels working better than pain killers. Not very good to be a taxi driver whene have neck pain and alcohol in my blood.
However, like to thank you Prof. Ernst for your wise words. Better to be live with neck pain than cadaver and not in pain.
BW thanks for pointing this out – I had forgotten this little untruth by the GCC; they really do not seem to have any shame at all.
Ernst is an infamous medical demagogue who speaks nonsense. While he trash talks chiropractors, he fails to mention nearly one million people in the USA will die from medical errors annually.
Let’s compare malpractice rates as proof which profession is most dangerous. The local neurosurgeon pays nearly $200,000 annually while I pay $1,600. So, who’s hurting patients the most? Certainly knife happy spine surgeons.
To read more about Ernst and his medical demagoguery, log on to Medical Goodfellas @ http://www.chiropractorsforfairjournalism.info/The_Medical_GoodFellas.html
I think you should have a slow read through Death by Medicine…
JC Smith MA DC wrote: “Ernst is an infamous medical demagogue who speaks nonsense. While he trash talks chiropractors…”
I don’t think so. He puts chiropractors in their place and they don’t like it. It’s really that simple.
Speaking of trashing…
Medical overutilisation of surgery for back pain does not vindicate chiropractic
Alan Botnick, DC, criticises JC Smith’s book, The Medical War against Chiropractors: The Untold Story from Persecution to Vindication. (Amazon, 2011)
‘The Medical War Against Chiropractors: The Untold Story from Persecution to Vindication’
Author: Smith JC. REVIEW: “This book is focused on the unfortunate legal battle between the American Medical Association (AMA) and the US chiropractic profession. It could be an interesting historical exposé but, unfortunately, JC Smith spoils it thoroughly by his entirely one-sided, biased view and inflammatory language. Smith goes not one but several steps too far and thus loses all credibility. For instance, he repeatedly compares the ‘medical lynch mob’ to Nazis and extreme racists: ‘Just as the Nazis used the Big Lie to undermine the image of Jews, so did the AMA use its own version of the Big Lie to defame the chiropractors’ (p. 132). Elsewhere, Smith states that the actions of some medical professionals in Florida were ‘clearly reminiscent of the days of racial desegregation in the South’ (p. 179). This is a great shame, not least because the tensions between the two professions would deserve a scholarly evaluation. I suspect that a sober analysis would have put the clinical evidence in the centre; an aspect that Smith avoids almost entirely. The tensions, I fear, are not between two groups fighting over the same patients, but between one group believing in science and evidence and the other having very little more than aggressive promotion. As it turns out, this book is not an analysis of a 130-year-old conflict but provides a wealth of misguided concepts; it is also a rich source for rampantly paranoid ideas that sadly still exist in the chiropractic profession.”
Edzard Ernst, Focus on Alternative and Complementary Therapies [FACT] (March 2012)
A chiropractor strikes back
“…I came across a hilariously paranoid post by a chiropractor calling himself J. C. Smith (JCS), who runs a website called Chiropractors for Fair Journalism…The article starts with the typical canards laid down by chiropractors about how horrible the American Medical Association is and how it supposedly tried to shut down chiropractic (as though that were a bad thing), referring to the AMA as a “medical mob” and referred to Morris Fishbein, MD, former director of the AMA as a “longtime medical godfather” and the “medical Mussolini.” JCS then equates opposition to the pseudoscience and quackery that underlie chiropractic with “bigotry”…Never mind that chiropractic is unscientific. Never mind that there is no such thing as a subluxation. Never mind that it’s nonsense that chiropractic is superior to medical care for spinal disorders…”
Orac at Respectful Insolence (July 2012)
A chiropractor strikes back at the Institute for Science in Medicine…again
“In the end, this follow up post attacking ISM [Institute for Science in Medicine] is risible in the extreme, relying primarily on tu quoque arguments, emphasizing harm that conventional medicine can cause while not balancing it with the good, personally attacking people…and in general using the same old fallacies favored by cranks and quacks.”
Orac at Respectful Insolence (20th July 2012)
[Includes a critical assessmement of ‘death by medicine’]
The war against chiropractors
A critical review of J.C. Smith’s book, The Medical War Against Chiropractors: The Untold Story from Persecution to Vindication: “Nowhere does he mention chiropractors like Sam Homola, who have criticized chiropractic from within. Nowhere does he mention that half of chiropractors are still undermining public health by discouraging immunizations. Nowhere does he acknowledge or respond to the arguments against chiropractic, for instance the wealth of material on Quackwatch’s Chirobase, Homola’s numerous books and articles, and magazine and blog articles by me, Steven Novella, David Gorski, and many others. Nowhere does he acknowledge the critiques of the Cassidy stroke study and the other studies he cites, [and] throughout, he confuses chiropractic with spinal manipulation.”
Harriet Hall MD, Science Based Medicine (23rd October 2012)
@JC Smith, MA, DC
Oh dear. There are many good websites on fallacies on the Internet (such as this one) that might help you understand some of the problems with your comment.
Fortunately, all is not what it seems…
Blogging: Zeno’s Blog » A right Royal chiro cock-up
J C Smith does an excellent job at discrediting himself/herself and his/her arguments simply by the language he/she uses. Well done!
Edzard: Why you need to see things always on “scientific” side when “science” is for you to discredit all who not think same way. Hope, you as a scientist learn one day that there is not really black and white on science. Oh, sorry, I must be black when wrote this. Live, love and learn dude. Make it easier for your family, friends and people around you. They might not find solution for their problems from allopathic approach.
Thanks for the advice Jani; I’ll consider learning…..but not from you.
Yes, true- nothing really to learn.
Recent systematic review and meta-analysis on this topic by Neurosurgeons not chiropractors! Interesting!
Surely you read my comment about that paper earlier this week?
To save readers time, here it is again:
Re your support of a Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation, a couple of medical doctors have already torn that paper to shreds. Here are their conclusions:
Harriet Hall, MD
“I ask you to imagine that there is a pharmaceutical drug that fits this description. Imagine that there are the same numbers of studies showing an association of that drug with a deadly side effect like stroke or death. The FDA would pull it off the market; they wouldn’t wait for definite evidence of causation that fulfilled all of Hill’s criteria. And I think the people who are making excuses for neck manipulation would want them to take that drug off the market. I don’t think they would want to take such a drug.”
Mark Crislip, MD:
“If chiropractic neck manipulation were a medication? Based on the severity of the potential reaction it would have a black box warning in the PDR. If side effects were combined with efficacy, chiropractic would never be approved, much less make it out of clinical trials.”
Peter Chapman wrote on Wednesday 24 August 2016 at 01:36 : “Check with your countries code of conduct and see if they are following it.”
@ Peter Chapman
1. The public in the UK is not furnished with such a detailed checklist (about finding an evidence-based chiropractor) that you provide in your comment. So, I ask again, how would a member of the public distinguish between a reputable registered chiropractor and a disreputable registered chiropractor when consulting the UK General Chiropractic Council’s register?
This, by the way, is what the public is up against:
“The GCC is a small body and self-funding. It therefore doesn’t have the resources to ‘police’ chiropractors and instead, relies on patients, fellow professionals and members of the public letting us know if there are concerns about a chiropractor. The GCC will then look into those concerns.”
2. FYI, chiropractors in the U.S. are allowed to diagnose chiropractic ‘subluxations’ even although they don’t exist:
“When the Council on Chiropractic Education (CCE) published its proposed 2012 Accreditation Standards for chiropractic colleges, reference to the word “subluxation” was omitted. The American Chiropractic Association (ACA) responded, in part, arguing that “The elimination of any reference to this term in the proposed standards will be viewed by many within the profession as a counter productive action that will, in the long-term, likely weaken the profession’s collaborative strength and historical identity.“ The CCE compromised by using the nebulous phrase “subluxation/neuro-biomechanical dysfunction” in the final 2012 Standards in order to satisfy advocates of the vertebral subluxation theory. (An open letter to the profession from CCE, Nov 22-11) Obviously, the factory of the chiropractic profession has not discarded subluxation theory. Chiropractic associations continue to reflect the views of the majority, even if such views are based on a belief system.”
3. The Chiropractic Board of Australia is, apparently, a joke…
If the people ask the questions in points 1-5 of my last comment then they should be able to work out which chiros are evidence based. They can also read the Australian chiro board code of conduct to get an idea. It isn’t really that difficult.
Simon Floreani is a joke and considered as such by most of the chiros I know. I wouldn’t take too much of what he says to be important.
The board isn’t as strong as I would like it to be but it is improving all the time and bringing chiros to task on advertising and treatment etc as specified in the guidelines.
“Simon Floreani is a joke and considered as such by most of the chiros I know…”
and why does the profession not rid itself of its ‘jokes’?
Good question. If I had my way we would. Chiros who are evidenced based get a hard time from others within the profession and some of them leave. I think the board is doing it correctly by changing the codes of conduct over time to allow chiros to change. If they don’t then they have to face the board.
that’s hardly good enough, in my view.
So you can only work out whether the chiro is ‘evidence-based’ after you’ve paid for your first session?
No you don’t have to wait until the end of your first session. Some of my points can be asked over the phone.
Despite that you are not able to know whether you have a good chiro, doctor, plumber etc until you have used them.
Im Australia you can look up the register and see if the chiropractor has any action against them by the board.
You do if they only tell you you need an excessive treatment plan after they’ve examined tou. Or do they tell you that before they’ve even examined you?
As for knowing about a good doctor, we have the Care Quality Commission in the UK. It comes in for criticism but alt least it inspects GP surgeries, hospitals, etc. But not chiros, of course because they’re CAM. And proper doctors are subject to revalidation. Chiros are not.
Yes, we can also check the GCC’s register, but the usefulness that depends on them properly policing their registrants in the first place, doesn’t it?
From comments I’ve read on this blog, chiropractic is defined essentially as ‘whatever an individual practitioner chooses’. Small wonder then that ‘official’ boards a consumer might normally expect to offer some sort of standards and regulation of the ‘profession’ turn out to be dissembling, weaselly worded shams that protect only the practitioners of this particular branch of Big Snakeoil.
Labelling all chiropractic as a snakeoil is not fair on those chiropractors who are trying to make changes. All professions have their radicals including medicine. Instead we should be encouraging the public to seek out the ethical and science based practitioners in all fields
Blue Wode said:
If they really were concerned about protecting the public, they would charge a fee that would allow them to do that job. The Chiropractors Act 1994 does not mandate a maximum fee: that they choose to not charge one that allows them to do what they are mandated to do – to regulate the ‘profession’ of chiropractic – speaks volumes. That noise you hear is the wringing of hands in Wicklow Street.
As far as I am aware, at least in Australia the medical profession doesn’t have a maximum fee set. It would be anti competitive to regulate the price of one health profession and not others.
Unfortunately there doesn’t seem to be a very effective way to protect the public as all health professions have some practirionets that harm patients
So they could – if they were so inclined – set a higher fee that enabled them to properly police their members.
I said nothing about regulating the price of membership.
But you may be interested to note that the UK’s GCC lowered their membership fees substantially a few years ago when they could well have spent the money properly policing their registrants. I wonder why they did that?
Alan. I thought you meant the fees the patient pays. In Australia it is different.
As I mentioned before it is often the case that you don’t know if someone is good or bad until you have tried them. It is the same in all professions.
Anyway it seems pointless to continue the dialogue as it seems the UK is very different from Australia.
Peter Champan said:
No, I was clearly referring to the registration fees by the so-called regulator. If that had higher fees, they might be able to properly police their registrants.
No it’s not, as I’ve already explained. Then there’s the issue of the evidence base – or otherwise – of their treatments.
It seems what we do have in common is that we have statutory chiro regulators who are not as concerned about protecting the public as they could or should be.
Alan Henness wrote: “If they [the GCC – UK General Chiropractic Council] really were concerned about protecting the public, they would charge a fee that would allow them to do that job. The Chiropractors Act 1994 does not mandate a maximum fee: that they choose to not charge one that allows them to do what they are mandated to do – to regulate the ‘profession’ of chiropractic – speaks volumes. That noise you hear is the wringing of hands in Wicklow Street.”
Let’s not forget that the GCC reduced the cost of its registration fees in 2012…
A chiropractor-friendly move if ever there was one, IMO.
So Edzard what would be good enough? It is how doctors are regulated in Australia as well. The public or other health professionals put in a complaint and the appropriate board looks into. If that is not good for chiros then it shouldn’t be good enough for anyone. What would you suggest? I doubt that there will ever be a foolproof system.
is anyone putting in a complaint?
Yes they are. The board publishes its findings each year
We have mandatory reporting in Australia where if we do not report it we are put on disciplinary action
Peter Chapman said:
How interesting. Can you provide a link that gives more details?
I have provided the link earlier but will provide it again
All the guidelines are published here and for public usage
Ah. We’re talking about different things. The OP was about the risk of chiro neck manipulation and I was referring to the regulator properly regulating its registrants (rather than just protecting their title). You linked to a document that’s not about that or even AEs, but about ‘notifiable conduct’, defined as:
Can you see the difference?
Edzard Blue and Alan
It is very frustrating for evidence based chiros. I will illustrate with a case. An 84 year old female presented with severe lower back pain with radiation down her posterior thigh to just below the knee. She asked my opinion and after orthopaedic testing my diagnosis was an SI joint problem. She saw her GP who referred her to an orthopaedic surgeon, a neurologist and eventually a pain specialist. The GP did this because “chiros don’t know anything”. After 9 months on endone and lyrica the pain continued to get worse to a 9/10 constantly. The eventual diagnosis through imaging and steriod injections was an SI joint problem 9 months after I had diagnosed it. After 2 weeks of gentle mobilisation the pain is now 1/10 and the patient can perform all her daily activities.
It is frustrating for 3 reasons. The patient had 9 months of extreme pain that she did not need to have if I was listened to. The chiros that you are talking about would not have done the orthopaedic testing and just told the patient that she had subluxations. The last reason is that the GP put me in the same category as those chiros just mentioned. This is not in the patients best interest.
Yes there are dodgy chiropractors just as there are dodgy doctors, dodgy journalists, dodgy plumbers and so on. I refer to myself as a musculoskeletal practitioner these days as that is what I do but by law I have to practice under the title of chiropractor
Cool story but this is not evidence of anything, even if true.
A case study is evidence. I suggest you look up levels of evidence in science. I find it rather ironic that several posts on here that are all about evidence are done by people who it seems do not know what evidence is.
I have a masters and until recently was a university lecturer. I have 2 published articles in peer reviewed journals and I happen to be a chiropractor. Yes I do know what evidence is
perhaps you should read this
Hi Ezard. Thanks for the article. It was a good read. I would like to be clear on something. I am not saying that case studies etc are superior to or replace clinical trials. All I am saying is that in some areas it is the only evidence that we have. No evidence for something does not always mean evidence against it. If the benefit is outweighing the risk and you are not playing to people’s emotions or giving them false hope and they are improving then I ask why not do it?
I appreciate what you are trying to do with the blogs and articles. All i am trying to do is to get people to realise that some chiropractors are following the evidence and doing their best to change the way things are done.
I have not attacked anyone’s beliefs or opinions on here but unfortunately mine have been.
If people are so against something then they will never recognise the evidence. Chiros do it and so do scientists and other health professionals
“…in some areas it is the only evidence that we have.” IN SUCH CASES, IT IS BEST TO OPENLY ADMIT THAT WE HAVE NO EVIDENCE.
“No evidence for something does not always mean evidence against it.” NO, BUT IN HEALTH CARE, WE TRY TO USE THOSE TREATMENTS FOR WHICH WE HAVE GOOD EVIDENCE AND DROP THE OTHERS UNTIL THEY FULFILL THIS CRETERION.
” If the benefit is outweighing the risk…” HOW CAN YOU BE SURE ABOUT THE BENEFIT, IF THERE IS NO GOOD EVIDENCE?
At the risk of repeating myself… What is “science/evidence based chiropractic? How can that not be an oxymoron??
It is where a chiropractor uses the best available evidence to influence their treatment of their patients. As in all health professions double blind placebo trials are not always able to be done. There are not many double blinded placebo trials done for surgical procedures as far as I am aware.
There are many levels of evidence within science and as the term “best available evidence” suggests we use the best available evidence. Case studies and clinical experience are still evidence even though they are not high on the hierarchy. Most medical studies that I have read regarding treatment (except pharmaceuticals), diagnosis etc are only level III-3, one level up from case studies level IV – https://www.health.qld.gov.au/healthpact/docs/gen-docs/lvl-of-evidence.pdf
Experts do not always have it correct, they use the best evidence that is available to them at the time. If that evidence changes over time with increased knowledge or technology then practices change. The experts at one time said that the earth was flat, that disease was caused by bad air and so on.
Where would we be if people did not question the things that were considered to be correct at the time? Still thinking the earth is flat.
I thought the term was fairly self explanatory.
“Where would we be if people did not question the things that were considered to be correct at the time?” Chiropractic and other forms of pseudo-medicine have been barraged for years with questions, but practitioners don’t ever seem to “change over time with increased knowledge or technology”. They resort to excuses like “by law I have to practice under the title of chiropractor”. Nobody and no law is forcing you not to become a physio.
Where is your evidence for practitioners not changing Frank? My evidence is that the course now being taught at university in WA is better and different from what I was taught 16 years ago.
Why would I go back to university for another 4 years to do exactly the same as I am doing now? Doesn’t really make sense does it? So it isn’t an excuse it doesn’t make sense nor is it practical. I as a practioner am evidence based and ethical. I do not subscribe to the subluxation belief. I am not an anti vaxer. All my children and myself are fully immunised. I do not keep getting people to come back for imaginary conditions. I also accept that not all in my profession are like that.
The interesting thing is that I am open minded enough to know that there are flaws in what a lot of chiropractors do. I do not do them. You on the other hand have lumped me in with those chiropractors. This to me indicates that you are closed minded and not willing to accept that all within the chiropractic profession are not unethical and uneducated. What is your excuse for your closed mindedness?
“My evidence is that the course now being taught at university in WA is better and different from what I was taught 16 years ago.” That’s an opinion, not evidence.
“What is your excuse for your closed mindedness?” You call yourself a chiropractor. Guilt by association. From the Facebook page of a chiropractor (also, by coincidence, named Peter Chapman): “There are now some chiropractors who do not subscribe to the theory that some kind of segmental dysfunction in the spine can cause organic disease, but they are overshadowed by subluxation-based chiropractors who publish their own journals, using scientific-sounding jargon to defend implausible theories and dubious treatment methods.” (My emphasis.)
“Why would I go back to university for another 4 years to do exactly the same as I am doing now?” Surely there’s an exam you can take right now to prove that what you do is physiotherapy?
Why do you call yorself a “chiropractor” if you neither belive in nor practice chiropractic?