MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

The RCC is a relatively new organisation. It is a registered charity claiming to promote “professional excellence, quality and safety in chiropractic… The organisation promotes and supports high standards of education, practice and research, enabling chiropractors to provide, and to be recognised for providing, high quality care for patients.”

I have to admit that I was not impressed by the creation of the RCC and lately have not followed what they are up to – not a lot, I assumed. But now they seem to plan a flurry of most laudable activities:

The Royal College of Chiropractors is developing a range of initiatives designed to help chiropractors actively engage with health promotion, with a particular focus on key areas of public health including physical activity, obesity and mental wellbeing.

Dr Mark Gurden, Chair of the RCC Health Policy Unit, commented:

“Chiropractors are well placed to participate in public health initiatives. Collectively, they have several million opportunities every year in the UK to support people in making positive changes to their general health and wellbeing, as well as helping them manage their musculoskeletal health of course.

Our recent AGM & Winter Conference highlighted the RCC’s intentions to encourage chiropractors to engage with a public health agenda and we are now embarking on a programme to:

  • Help chiropractors recognise the importance of their public health role;
  • Help chiropractors enhance their knowledge and skills in providing advice and support to patients in key areas of public health through provision of information, guidance and training;
  • Help chiropractors measure and recognise the impact they can have in key areas of public health.

To take this work forward, we will be exploring the possibility of launching an RCC Public Health Promotion & Wellbeing Society with a view to establishing a new Specialist Faculty in due course.”

END OF QUOTE

A ‘Public Health Promotion & Wellbeing Society’. Great!

As this must be new ground for the RCC, let me list a few suggestions as to how they could make more meaningful contributions to public health:

  • They could tell their members that immunisations are interventions that save millions of lives and are therefore in the interest of public health. Many chiropractors still have a very disturbed attitude towards immunisation: anti-vaccination attitudes still abound within the chiropractic profession. Despite a growing body of evidence about the safety and efficacy of vaccination, many chiropractors do not believe in vaccination, will not recommend it to their patients, and place emphasis on risk rather than benefit. In case you wonder where this odd behaviour comes from, you best look into the history of chiropractic. D. D. Palmer, the magnetic healer who ‘invented’ chiropractic about 120 years ago, left no doubt about his profound disgust for immunisation: “It is the very height of absurdity to strive to ‘protect’ any person from smallpox and other malady by inoculating them with a filthy animal poison… No one will ever pollute the blood of any member of my family unless he cares to walk over my dead body… ” (D. D. Palmer, 1910)
  • They could tell their members that chiropractic for children is little else than a dangerous nonsense for the sake of making money. Not only is there ‘not a jot of evidence‘ that it is effective for paediatric conditions, it can also cause serious harm. I fear that this suggestion is unlikely to be well-received by the RCC; they even have something called a ‘Paediatrics Faculty’!
  • They could tell their members that making bogus claims is not just naughty but hinders public health. Whenever I look on the Internet, I find more false than true claims made by chiropractors, RCC members or not.
  • They could tell their members that informed consent is not an option but an ethical imperative. Actually, the RCC do say something about the issue: The BMJ has highlighted a recent UK Supreme Court ruling that effectively means a doctor can no longer decide what a patient needs to know about the risks of treatment when seeking consent. Doctors will now have to take reasonable care to ensure the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments. Furthermore, what counts as material risk can no longer be based on a responsible body of medical opinion, but rather on the view of ‘a reasonable person in the patient’s position’. The BMJ article is available here. The RCC feels it is important for chiropractors to be aware of this development which is relevant to all healthcare professionals. That’s splendid! So, chiropractors are finally being instructed to obtain informed consent from all their patients before starting treatment. This means that patients must be told that spinal manipulation is associated with very serious risks, AND that, in addition, ~ 50% of all patients will suffer from mild to moderate side effects, AND that there are always less risky and more effective treatments available for any condition from other healthcare providers.
  • The RCC could, for the benefit of public health, establish a compulsory register of adverse effects after spinal manipulations and make the data from it available to the public. At present such a register does not exist, and therefore its introduction would be a significant step in the right direction.
  • The RCC could make it mandatory for all members to adhere to the above points and establish a mechanism of monitoring their behaviour to make sure that, for the sake of public health, they all do take these issues seriously.

I do realise that the RCC may not currently have the expertise and know-how to adopt my suggestions, as these issues are rather new to them. To support the RCC in their praiseworthy endeavours, I herewith offer to give one or more evidence-based lectures on these subjects (at a date and place of their choice) in an attempt to familiarise the RCC and its members with these important aspects of public health. I also realise that the RCC may not have the funds to pay professorial lecture fees. Therefore, in the interest of both progress and public health, I offer to give these lectures for free.

I can be contacted via this blog.

35 Responses to The Royal College of Chiropractors’ focus on key areas of public health – plus my constructive suggestions

  • Royal? Who did that?

      • @ Simon Baker

        Click on ‘meddling’ in the last line here:
        http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/2190-jubilation-in-the-chiropractic-world-but-as-usual-all-is-not-what-it-might-seem-at-first.html

        For those who don’t have time, here is the gist of it:

        QUOTE
        “The College of Chiropractors has, indeed, been granted a Royal Charter, but it’s a Royal Charter of Incorporation, granted by the Privy Council, with Nick Clegg as Lord President…The College claims it “currently has more than 1500 UK members and 2800 members worldwide.” That adds up to just 4,300 members (with only 1,500 in the UK), somewhat short of the requisite 5,000. Or does that 2,800 include its 1,500 UK members? In which case, it’s even further off meeting the 5,000 requirement. But why only 1,500 members in the UK? There are 3,374 chiropractors registered with the General Chiropractic Council, so the College of Chiropractors doesn’t even represent half of the chiropractors in the UK. Is this further evidence to the split between the different chiro factions?…The grant of the Royal Charter on 7th November followed a letter of support from Department of Health dated 26th September 2012 to the President of the College to say the Department would be advising the Privy Council that the College’s charter application should be taken out of abeyance. So, despite the College failing to meet the requirements set out by the Privy Council, it was interference in that process by the DoH that produced the Royal Charter a mere weeks later. Once we have that letter, we’ll let you know what it says. Meddling, anyone?”

    • We’ve got cloth-brained Charlie to thank for that.

  • And what exactly is the process by which they became entitled to use the word ‘royal’?

  • I remain totally bemused.
    If these ladies and gentlemen want to practice in the sphere of public health, why don’t they train to do so and qualify first as doctors and then as specialists in public health?

    We should be told.
    And moreover, so should their patients, with a clear explanation as to why they trained in chiropractic and not physiotherapy.

    The only explanation I can think of is that:
    “I came to believe, for no evidence-based reason, that the system of healthcare devised by a magnetic healer, and developed, in his own words, as a system ‘different to medicine’, releases ‘innate intelligence’ by adjusting ‘subluxations’ which have only ever been identified by chiropractors, yet which have wondrous results. Physiotherapy and medicine were too demanding for me.”

    Are there any other explanations?

  • The conjoining of the words “Royal” and “Chiropractors” via the words “College of” may do the CV of chiropractic a power of good. It substantially diminishes the cachet of the words “Royal College”.

    I’ve notified the college that their “evidence for chiropractic” page is out of date.

    They quote the 2009 NICE guidance recommending acupuncture for low back pain.

    It also reads as if exercise and chiropractic for LBP are alternatives, whilst the 2016 NICE update says chiropractic should be considered as an adjunct to exercise.

  • It appears that The University of Birmingham is offering two subsidised Master of Science scholarships in Manipulative Physiotherapy. It appears that spinal manipulation is a needed intervention that must be included in the management of spinal pain and high-level sports performance.
    Here is the link to the offered UK course:https://www.birmingham.ac.uk/Documents/college-les/sportex/physiotherapy/msc-student-funding-opportunity.pdf
    I am sure that they could learn a lot from the chiropractic profession on the science of spinal health. Here is the link to the evidence-based approach used by chiropractors. https://idealspine.com/what-is-cbp/
    As the Lancet’s recent publication on the management of low back pain states, it is time for chiropractic, medicine and physiotherapy to collaborate so as to better understand each other. https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)30489-6.pdf?code=lancet-site

    • Howsoever chiropractors employ the term “evidence based”, in terms of medical treatments it refers to clinical evidence of safety and benefit of treatments. The use of the term in your link is of no consequence to patients if chiropratic treatment has no solid evidence base to support it.

    • The central message I take from The Lancet study is that there is a gap between evidence and practice and the unifying motif across national guidelines, other than reassuring patients that their back pain will dissipate and disappear in time, is to encourage patients to be as active as possible, meaning to carry on with normal life as well as they can manage to do so and better still to EXERCISE!

    • @ME: What do Chiropractors know about the “science of spinal health”?? When Harrison applied physics and mechanical engineering principles to ‘spinal/global-posture” treatments he by logical necessity stepped diametrically away from ‘chiropractic’….which is a religion based on Supra-mundane insights and revelation, physics have no place. He maintained his affiliation and propinquity with the ‘profession’ for obvious reasons….he had a fairly large, established audience which he was well adapted to sell to and educate. He shifted the cheese from suggesting intervertebral-subluxations having catastrophic “health consequences” to suggesting “global posture distortions” are the real issue.
      Harrison died young from the consequences of obesity, not posture?
      So stealing real science from biomechanical engineers and positing it into a poorly educated, religiously imbued profession of quacks grants them the ability to suggest they are expert in the “science of spinal health”??
      I’ve been waiting for years to see the large population studies proving the wildly expensive, uncomfortable and expensive ‘treatment protocol’ (better described as an addiction) of/to CBP actually make a discernible difference in long term health or function….vs anything else or nothing else. In Harrison’s case it didn’t appear to help much. I have several very functional plus 90 year olds in my family and none have ever concerned themselves in posture or posture “traction” or spinal manipulation for that matter. Admittedly an anecdote but that’s all you charlatans ever invoke as well.

      • Here is the RCT you have been waiting for on a common CBP lumbar traction procedure. Just for clarification, when combined with manipulation and a bit of adaption time, this type of traction feels quite pleasurable.

        • @ME: Do you anticipate those of us who have skeptical opinions of quackery don’t know of these studies? This study is 6 years old as well….So Have there been replications? And isn’t CBP approaching it’s 40th anniversary? And this is what you point to as definitive population-studies demonstrating distinct superiority over less burdensome and less costly methods?? And do you anticipate this study proves a marked benefit-to-cost ratio of these methods?
          Is the follow-up time frame really of sufficient duration to make the covert suggestion CMLBP is somehow ‘cured’ by coercion-of-lordosis? Or that no other (non-postural/non-chiropractic) treatments have ever resulted in a 6-month improvement in pain vs. X?
          What of the millions whose pain is improved by simple, inexpensive exercise and better daily health-choices alone?? Or those billions of Homo-sapiens-sapiens prior-to the “LBP epidemic” who never gave a moments’ thought to their lordosis….and lived out their life without overt disability ?
          Is the NIH, WHO etc falling over themselves to rewrite best-evidence LB guidelines to include these burdensome, uncomfortable, x-Ray-based, Chiropractor-controlled “$88 per consultation”, 40+ session “curve-restoration”…..treatments???? A treatment method so compelling that after 40 years a whooping 10% of DCs choose it as their primary technique? And ZERO colleges teach it as THE TRUE Chiropractic…..
          Is that where you are going with this??
          Should this ‘restorative-“care” be trusted to the hands of quackopractors with their innumerable arcane auspices loaded with useless trappings of pseudoscience, trickery and anti-science rhetoric? Or is it reserved for the brilliant, Reformed DCs (like you) taking charge ? You just KNOW this shit has profound value and far-reaching implications for human wellbeing………But HOW?? You see it “working” daily? Is that it? The way Scientologists hear LRH telling them to get more auditing?
          Perhaps CPBP (corrective-postural bio-physics) makes more sense than destroying all credibility with real-science by putting the word chiropractic in front ? As a matter of fact where does a DC degree even enter into this discussion? It was Harrison’s real degrees that gave the pith to his insights. The “chiropractic” aspects simply gave it it’s bullshit rhetoric and pecuniary reward system.
          I’d say it’s mirror-image traction that may restore curves, if in fact it does…not spinal “adjustments”, or other chiropractic-BS. And traction ain’t Chiropractic no matter how important keeping up the ruse is for your income stream.
          If it wasn’t for hyperbole and bait-&-switch you’d be getting $20.00 per session and lucky to get that.

        • Link says “Oops! We encountered an unexpected error. Please try again.” (Repeatedly)

        • I am neither sure what you are trying to tell us Mr. Epstein nor what this has to do with chiropractic (in the proper meaning of the term).
          Who of us have been waiting for this RCT and why should we?

          The full text article is not accessible. The abstract tells us that 40 persons with chronic mechanical(whatever that is) lower back pain were given heat and stretching and 40 more with the same problem were also given heat and stretching in addition to a bit more stretching. This is the classic A vs A+B method of producing the fallaciously “positive” inference that B is efficacious because A + B is better than A alone. There was no effect on pain and disability score at ten weeks so the measured parameters could hardly be clinically significant and there is no mention of observer blinding (or any blinding for that matter).
          So I have a very hard time believing there is any true, clinically significant efficacy of the added traction (the “B”). The claim in the abstract of a significant difference in all parameters at six months is somewhat obscure and supported with a ” p< 0.05 " whereas the previous results were supported with exact p to three decimals. This, and the fact they do not state the observed differences along with their ranges and CI's makes me suspicious that the authors are bloating the (unblinded?) long term observations and the authors and reviewers, if any, have very limited understanding of statistics and research methodology.
          Smells of junk science.

        • Do not offer traction for managing low back pain with or without sciatica

          NICE:Low back pain
          https://www.nice.org.uk/guidance/NG59/chapter/Recommendations#invasive-treatments-for-low-back-pain-and-sciatica

      • Been busy with patients but here is another RCT on chiropractic traction protocol.
        Notice the improvement in the H reflex in the traction group which suggests better nerve conductivity.
        https://www.ncbi.nlm.nih.gov/pubmed/22684211

      • Here is another RCT study on the positive use of spinal remodelling traction, but for the cervical spine. https://www.ncbi.nlm.nih.gov/pubmed/27576192?option=com_content&view=article&id=6&Itemid=7

      • Another RCT as it relates to the use of traction for the management of cervicogenic dizziness. https://www.ncbi.nlm.nih.gov/pubmed/27575013?option=com_content&view=article&id=6&Itemid=7

        • @ME: You keep stuffing “Chiropractic” into this multi-modal rehab….but have bashed ‘subluxation’? Bending someone in the opposite position they present with….is this NOW Chiropractic? And without this traction do patients never recover? Are your DC colleagues happy with that pronouncement?
          So “chiropractic” without postural traction is….ineffective? Making hyperbolic claims? Lying to the public regarding “fixing the source” of pain? I’m still confused? Once “corrected” everything is AOK?

        • All three study designs are A+B vs A.

  • Leigh Jackson wrote on Friday 27 April 2018 at 12:21: “I’ve notified the college that their “evidence for chiropractic” page is out of date. They quote the 2009 NICE guidance recommending acupuncture for low back pain. It also reads as if exercise and chiropractic for LBP are alternatives, whilst the 2016 NICE update says chiropractic should be considered as an adjunct to exercise.”

    The British Chiropractic Association (BCA) also carries that outdated information on the ‘For Healthcare Professionals’ page of its website:
    https://chiropractic-uk.co.uk/for-health-care-professionals/

    It can be found in its leaflet entitled ‘Information for GPs and Healthcare Professionals’:
    https://chiropractic-uk.co.uk/wp-content/uploads/2016/04/HC-Professionals-Leaflet.pdf

    I have notified the BCA about it on Twitter, accompanied by this comprehensive link
    https://complementaryandalternative.wordpress.com/2016/12/06/nice-guidelines-for-low-back-pain-and-sciatica-a-clarification/ but they have yet to thank me for my alert.

    Perhaps worse, though, is that the General Chiropractic Council is similarly guilty. They were informed a while back of their error although they don’t seem to have corrected it yet:
    http://www.gcc-uk.org/UserFiles/Docs/ABOUT%20US/Seeing%20a%20chiropractor%20for%20the%20first%20time.pdf

    Interestingly, other research references given by the BCA in its ‘Information for GPs and Healthcare Professionals’ leaflet – which are either out of date or unreliable – are:

    Airaksinen O, Brox JI, Cedraschic C, Hildebrandt J, Klaber-Moffett J, Kovacs F, et al Chapter 4, European Guidelines for the Management of Chronic Non-Specific Low Back Pain European Spine Journal 2006, 15 Suppl. 2: S169-S191

    Critique: Only a brief mention is made for spinal manipulation and not ‘chiropractic’ in these guidelines. Bearing in mind that Alan Breen, DC (who at the time of their publication was Professor of Musculoskeletal Health Care at the Anglo European College of Chiropractic), collaborated in the development of the European Acute Back Pain Guidelines, this is what Professor Ernst had to say about them:

    Quote:
    “Chiropractors argue that their approach must be safe and effective, not least because the official guidelines on the treatment of back pain recommend using chiropractic. However, this is true only for some, but by no means all, countries. Secondly, guidelines are well known to be influenced by the people who serve on the panel that develops them. Cochrane reviews, on the other hand, are generally considered to be objective and rigorous. Writing about the importance of systematic reviews for health care in the Lancet, Sir Ian Chalmers stated, ‘I challenge decision makers within those spheres who continue to frustrate efforts to promote this form of research to come out from behind their closed doors and defend their attitudes and policies in public. There is now plenty of evidence to show how patients are suffering unnecessarily as a result of their persuasive influence.’”

    Ref: The Value of Chiropractic https://onlinelibrary.wiley.com/doi/full/10.1211/fact.10.2.0001

    BEAM Trial Back Pain, Exercise and Manipulation Randomised Trial; Effectiveness of Physical Treatments for Back Pain in Primary Care British Medical Journal Nov 2004; 329; 1377 (doi 10.1136/bmj. 38282.669225.AE)

    Critique by Professor Ernst in the BMJ:

    “Three brief comments on the excellent BEAM Trial.
    My reading of the results is that the data are compatible with a non-specific effect caused by touch: exercise has a significantly positive effect on back pain which can be enhanced by touch. If this “devil’s advocate” view is correct, the effects have little to do with spinal manipulation per se.
    It would be relevant to know which of the three professional groups (chiropractors, osteopaths, physiotherapists) generated the largest effect size. This might significantly influence the referral pattern. A post-hoc analysis might answer this question.
    It is regrettable that the study only monitored serious adverse effects. There is compelling data to demonstrate that minor adverse effects occur in about 50% of patients after spinal manipulation. If that is the case, such adverse events might also influence GP’s referrals.”

    Ref http://www.ebm-first.com/chiropractic/the-meade-report-criticism/1368-the-beam-trial.html

    Haldeman S, Carroll L, Cassidy D, Schubert J, Nygren A The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Executive Summary Spine 2008 33 S5-S7

    Critique: “…the Bone and Joint decade is very muted in its endorsement of manual therapies of neck pain, regarding them as about equal to five or six non-manipulative approaches including laser therapy and massage. These others possibly perform only marginally better than placebo, if at all, when you take into account the difficulties in blinding studies of such interventions. That publication also blithely dismisses the question of stroke by reference to a single study [the notorious study by Cassidy et al which has been critiqued in the comments above] which did not even directly establish which patients had their necks manipulated and which did not. It also ignored many simple observations that make it extremely unlikely that specific strokes preceded manipulation.”

    Ref. Comment 33 from an MD here:
    http://www.sciencebasedmedicine.org/neck-manipulation-risk-vs-benefit/

    Returning to the Royal College of Chiropractors, it also cites some of the above studies on its ‘Evidence for Chiropractic’ page https://rcc-uk.org/evidence-for-chiropractic/ and also includes this dubious one:

    Effectiveness of Manual Therapies – The UK Evidence Report
    ‘This review, by Bronfort et al, was published in the journal Chiropractic & Osteopathy in 2010. Commentaries by Professor Scott Haldeman and Professor Martin Underwood accompany the report. In summary, the report demonstrates robust randomised controlled trial (RCT) evidence that the care offered by chiropractors is effective for a wide range of conditions including back pain, neck pain, pain associated with hip and knee osteoarthritis and some types of headache.’

    Critique: All of the claims listed as evidence-based can be challenged by evidence-based reviews not mentioned in the paper. Even if the claims are valid for manipulation, they aren’t necessarily valid for chiropractic overall as practiced in the real world.

    Critique: “Bronfort’s overview was commissioned by the General Chiropractic Council, it was hastily compiled by ardent believers of chiropractic, published in a journal that non-chiropractors would not touch with a barge pole, and crucially it lacks some of the most important qualities of an unbiased systematic review. In my view, it is nothing short of a white-wash and not worth the paper it was printed on. Conclusions, such as the evidence regarding pneumonia, bed-wetting and otitis is inconclusive are just embarrassing; the correct conclusion is that the evidence fails to be positive for these and most other indications.”

    Ref: http://edzardernst.com/2013/08/evidence-based-chiropractic-is-an-oxymoron/

    Critique: “This review of all manual therapies focusses mainly on spinal manipulative therapy and massage therapy for low back and neck pain, with underwhelming results: both are “effective” in some circumstances but certainly not impressively so, and generally no different from other therapies that help a little but haven’t exactly put a dent in the epidemic. For instance, the authors write that SMT is effective but “similar in effect to other commonly used efficacious therapies such as usual care, exercise, or back school.” Unfortunately, “back school” is not exactly well known for curing low back pain.” Together, the Bronfort and Rubinstein reviews make it clear that spinal manipulative therapy is probably only of minor clinical value, at best.

    Ref: http://www.sciencebasedmedicine.org/reference/chiropractic/

    Critique: “…the word “negative” (of evidence) occurs 0 times in the article text or abstract, “positive” (of effect) 1 time (0 in the abstract), and the word “inconclusive” 47 times (4 in the abstract). And “inconclusive” here of course means “almost positive” for them, particularly the “Inconclusive but favorable” category. Of the 65 conditions studied, they deemed 19 as having “positive” evidence for chiropractic treatment, 40 as “inconclusive”, of the “inconclusive”, no less than 27 were counted as “favorable” and 6 as negative. With a clearer eye, this means 46 negative vs 19 positive. But the abstract reflects this only very vaguely, and many people don’t read the rest, perhaps. Lots of wishful thinking there.”

    Ref: http://edzardernst.com/2014/02/the-alchemists-of-alternative-medicine-part-3-the-non-conclusive-method/#comment-54409

    IMO, in view of the above, it is a major public health concern in itself that supposedly respectable chiropractic bodies are blithely asserting that they are supporting high standards of education, practice, and research.

    • very true!

    • which body does one complain to, if the regulators are guilty of irregularities?

    • The RCC did respond promtly to my prompt. They now quote the NICE update for low back pain. Mention of acupuncture has gone and they now make clear that manual therapies must be accompanied by exercise.

      If NICE backed up the other papers quoted by the RCC, chiropractic could fairly claim to to have a firm evidence base. As they state: “NICE is an independent organisation”.

      But NICE does not provide an independent agreement with the other studies. The fact that NICE does not do so leaves the RCC hanging by an evidence thread. Namely the single thread that chiropractic may be considered as an adjunct to exercise for low back pain.

      By failing to make the same recommendations for other conditions NICE undermines those other studies.

      Furthermore the NICE guidance was issued in 2016. Brontfort and the RCC commissioned update to Brontfort – the Warwick Report – were published in 2010 and 2011.

      In other words NICE is the most up to date evidence available, a fact which is not evident on the RCC update to their website.

    • Well I suppose manipulating the spine and manipulating evidence are similar “skills”?

  • @BW: thank you for your detailed and insightful posting! Really extraordinary!
    And it will be ignored or ‘blithely’ side-stepped by the Dedicated Charlatans whose IQs are just high enough to be able to read this blog….but too low to actually comprehend it.

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