chiropractic
Chiropractors will never cease to amuse and amaze me. Today, I received this comment to a recent post of mine; its author is a chiropractor by the name of SD White (I never met the man [surely it’s a man] and don’t know where he’s from):
Someone is suffering from a love of credentials (small penis?) and a sour disposition who has zero actual information about a profession of which he is not a member. So this is how you choose to spend your days? What a royal disappointment you must be to family, friends, and others with your extremely disjointed and disgruntled opinions. Which no one requested. Rating: 1/10
This type of hilarity encouraged me to write a post about chiropractic which fulfils some of SD White’s criteria: no one requested it, and it has zero actual information. But I hope it adds to the hilarity chiropractic so often creates.
The article it refers to is entitled ‘Chiropractic in global health and well being’. When I read such a headline, my BS-detectors starts running amok, and my BS-corrector automatically springs into action.
In the following, I will show you some excerpts from this paper – first in its original version and subsequently in the version altered by my BS-corrector.
ENJOY
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The abstract:
The World Federation of Chiropractic supports the involvement of chiropractors in public health initiatives, particularly as it relates to musculoskeletal health. Three topics within public health have been identified that call for a renewed professional focus. These include healthy ageing; opioid misuse; and women’s, children’s, and adolescents’ health. The World Federation of Chiropractic aims to enable chiropractors to proactively participate in health promotion and prevention activities in these areas, through information dissemination and coordinated partnerships. Importantly, this work will align the chiropractic profession with the priorities of the World Health Organization. Successful engagement will support the role of chiropractors as valued partners within the broader healthcare system and contribute to the health and wellbeing of the communities they serve.
Passage from the paper:
The WFC’s Public Health Committee has committed to an expanded agenda that focuses on three new priority areas of public health: healthy ageing; opioid overuse and misuse; and women’s, children’s, and adolescents’ health. These were chosen for their alignment with WHO priorities, and the chiropractic profession’s ability to uniquely contribute to each through the lens of musculoskeletal health. The goal is to enhance the ability for chiropractors to actively engage in health promotion activities in alignment with WHO priority areas and pursue collaborative work to increase global attention on these important public health issues. As a first step, the WFC will focus on providing key strategies that chiropractors in primary care settings can focus on bridging their work in primary care and population health. The WFC has developed position statements and proposed public health strategies for each priority area, as described below.
The conclusion
The WFC commits to promoting and facilitating public health strategies for chiropractors to implement in practice. Healthy ageing, opioid misuse, and supporting women’s, children’s and adolescents’ health are priority areas of initial focus. This work builds on the shared goal of primary care and population health, through the prevention of illness, promoting health, improving patient care, and addressing contextual factors in a collaborative and evidence-based manner. Future work in public health for the chiropractic profession should also focus on broader roles such as community engagement and the creation of sustainable systems, engaging key stakeholders locally and globally.
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VERISON BY BS-CORRECTOR
The abstract:
The World Federation of Chiropractic supports the involvement of chiropractors in fleecing the public, particularly as it relates to musculoskeletal health. Three topics within chiropractic wealth have been identified that call for a boost in our cash flow. These include healthy ageing; opioid misuse; and women’s, children’s, and adolescents’ health. The World Federation of Chiropractic aims to enable chiropractors to proactively participate in misinforming the public in these areas, through coordinated partnerships with anyone who can be fooled. Importantly, this work will be camouflaged such that it seemingly aligns the chiropractic profession with the priorities of the World Health Organization. Successful engagement will support the wealth of chiropractors within the broader healthcare system but will contribute little to the health and wellbeing of the communities they pretend to serve.
Passage from the paper:
The WFC’s Public Health Committee has committed to an expanded agenda that focuses on three new priority areas for generating chiropractic wealth: healthy ageing; opioid overuse and misuse; and women’s, children’s, and adolescents’ health. These were chosen even though there is no good evidence to show that chiropractic might meaningfully contribute to any of them. The goal is to enhance the ability of chiropractors to actively engage in wealth creation activities in alignment with their financial aspirations. As a first step, the WFC will focus on providing key strategies that chiropractors in primary care settings can focus on for misleading the public. The WFC has developed position statements and proposed wealth strategies for each priority area, as described below.
The conclusion
The WFC commits to promoting and facilitating wealth strategies for chiropractors to implement in practice. Healthy ageing, opioid misuse, and supporting women’s, children’s and adolescents’ health are priority areas of initial focus. This work builds on many years of misleading the public into believing that chiropractors do more good than harm in any of these areas. Future work in generating wealth for the chiropractic profession should also focus on broader roles such as community engagement and the creation of sustainable systems, exploiting key stakeholders locally and globally.
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Yes, I know, my BS-corrector is very harsh, impolite and sarcastic. You must forgive it, please. I nevertheless hope this is a small contribution – not to chiropractic, but to its hilarity.
The Royal College of Chiropractors (RCC), a Company Limited by guarantee, was given a royal charter in 2013. It has following objectives:
- to promote the art, science and practice of chiropractic;
- to improve and maintain standards in the practice of chiropractic for the benefit of the public;
- to promote awareness and understanding of chiropractic amongst medical practitioners and other healthcare professionals and the public;
- to educate and train practitioners in the art, science and practice of chiropractic;
- to advance the study of and research in chiropractic.
In a previous post, I pointed out that the RCC may not currently have the expertise and know-how to meet all these aims. To support the RCC in their praiseworthy endeavours, I therefore offered to give one or more evidence-based lectures on these subjects free of charge.
And what was the reaction?
Nothing!
This might be disappointing, but it is not really surprising. Following the loss of almost all chiropractic credibility after the BCA/Simon Singh libel case, the RCC must now be busy focussing on re-inventing the chiropractic profession. A recent article published by RCC seems to confirm this suspicion. It starts by defining chiropractic:
“Chiropractic, as practised in the UK, is not a treatment but a statutorily-regulated healthcare profession.”
Obviously, this definition reflects the wish of this profession to re-invent themselves. D. D. Palmer, who invented chiropractic 120 years ago, would probably not agree with this definition. He wrote in 1897 “CHIROPRACTIC IS A SCIENCE OF HEALING WITHOUT DRUGS”. This is woolly to the extreme, but it makes one thing fairly clear: chiropractic is a therapy and not a profession.
So, why do chiropractors wish to alter this dictum by their founding father? The answer is, I think, clear from the rest of the above RCC-quote: “Chiropractors offer a wide range of interventions including, but not limited to, manual therapy (soft-tissue techniques, mobilisation and spinal manipulation), exercise rehabilitation and self-management advice, and utilise psychologically-informed programmes of care. Chiropractic, like other healthcare professions, is informed by the evidence base and develops accordingly.”
Many chiropractors have finally understood that spinal manipulation, the undisputed hallmark intervention of chiropractors, is not quite what Palmer made it out to be. Thus, they try their utmost to style themselves as back specialists who use all sorts of (mostly physiotherapeutic) therapies in addition to spinal manipulation. This strategy has obvious advantages: as soon as someone points out that spinal manipulations might not do more good than harm, they can claim that manipulations are by no means their only tool. This clever trick renders them immune to such criticism, they hope.
The RCC-document has another section that I find revealing, as it harps back to what we just discussed. It is entitled ‘The evidence base for musculoskeletal care‘. Let me quote it in its entirety:
The evidence base for the care chiropractors provide (Clar et al, 2014) is common to that for physiotherapists and osteopaths in respect of musculoskeletal (MSK) conditions. Thus, like physiotherapists and osteopaths, chiropractors provide care for a wide range of MSK problems, and may advertise that they do so [as determined by the UK Advertising Standards Authority (ASA)].
Chiropractors are most closely associated with management of low back pain, and the NICE Low Back Pain and Sciatica Guideline ‘NG59’ provides clear recommendations for managing low back pain with or without sciatica, which always includes exercise and may include manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) as part of a treatment package, with or without psychological therapy. Note that NG59 does not specify chiropractic care, physiotherapy care nor osteopathy care for the non-invasive management of low back pain, but explains that: ‘mobilisation and soft tissue techniques are performed by a wide variety of practitioners; whereas spinal manipulation is usually performed by chiropractors or osteopaths, and by doctors or physiotherapists who have undergone additional training in manipulation’ (See NICE NG59, p806).
The Manipulative Association of Chartered Physiotherapists (MACP), recently renamed the Musculoskeletal Association of Chartered Physiotherapists, is recognised as the UK’s specialist manipulative therapy group by the International Federation of Orthopaedic Manipulative Physical Therapists, and has approximately 1100 members. The UK statutory Osteopathic Register lists approximately 5300 osteopaths. Thus, collectively, there are approximately twice as many osteopaths and manipulating physiotherapists as there are chiropractors currently practising spinal manipulation in the UK.
END OF QUOTE
To me this sounds almost as though the RCC is saying something like this:
- We are very much like physiotherapists and therefore all the positive evidence for physiotherapy is really also our evidence. So, critics of chiropractic’s lack of sound evidence-base, get lost!
- The new NICE guidelines were a real blow to us, but we now try to spin them such that consumers don’t realise that chiropractic is no longer recommended as a first-line therapy.
- In any case, other professions also occasionally use those questionable spinal manipulations (and they are even more numerous). So, any criticism of spinal manipulation should not be directed at us but at physios and osteopaths.
- We know, of course, that chiropractors treat lots of non-spinal conditions (asthma, bed-wetting, infant colic etc.). Yet we try our very best to hide this fact and pretend that we are all focussed on back pain. This avoids admitting that, for all such conditions, the evidence suggests our manipulations to be worst than useless.
Personally, I find the RCC-strategy very understandable; after all, the RCC has to try to save the bacon for UK chiropractors. Yet, it is nevertheless an attempt at misleading the public about what is really going on. And even, if someone is sufficiently naïve to swallow this spin, one question emerges loud and clear: if chiropractic is just a limited version of physiotherapy, why don’t we simply use physiotherapists for back problems and forget about chiropractors?
(In case the RCC change their mind and want to listen to me elaborating on these themes, my offer for a free lecture still stands!)
Currently, there are measles outbreaks almost everywhere. I have often pointed out that SCAM does not seem to be entirely innocent in this development. Now another study examined the relationship between SCAM-use and vaccination scepticism. Specifically, the researchers wanted to know whether a person’s more general health-related worldview might explain this relationship.
A cross-sectional online survey of adult Australians (N = 2697) included demographic, SCAM, and vaccination measures, as well as the holistic and magical health belief scales (HHB, MHB). HHB emphasises links between mind and body health, and the impact of general ‘wellness’ on specific ailments or resistance to disease, whilst MHB specifically taps ontological confusions and cognitive errors about health. SCAM and anti-vaccination were found to be linked primarily at the attitudinal level (r = -0.437). The researchers did not find evidence that this was due to SCAM practitioners influencing their clients. Applying a path-analytic approach, they found that individuals’ health worldview (HHB and MHB) accounted for a significant proportion (43.1%) of the covariance between SCAM and vaccination attitudes. MHB was by far the strongest predictor of both SCAM and vaccination attitudes in regressions including demographic predictors.
The researchers concluded that vaccination scepticism reflects part of a broader health worldview that discounts scientific knowledge in favour of magical or superstitious thinking. Therefore, persuasive messages reflecting this worldview may be more effective than fact-based campaigns in influencing vaccine sceptics.
Parents opposing vaccination of their kids are often fiercely determined. Numerous cases continue to make their way through the courts where parents oppose the vaccination of their children, often inspired by the views of both registered and unregistered health practitioners, including homeopaths and chiropractors. A recent article catalogued decisions by the courts in Australia, New Zealand, the UK and Canada. Most of them ruled in favour of vaccination and dismissed the arguments of those opposed to vaccination as unscientific. The author, an Australian barrister and Professor of Forensic Medicine, concluded that Australia should give serious consideration to emulating the model existing in multiple countries, including the United States, and should create a no-fault vaccination injury compensation scheme.
Such programs are based on the assumption that it is fair and reasonable that a community protected by a vaccination program accepts responsibility for and provides compensation in those rare instances where individuals are injured by it. To Me, this seems a prudent and ethical concept that should be considered everywhere.
Alternative practitioners practise highly diverse therapies. They seem to have nothing in common – except perhaps that ALL of them are allegedly stimulating our self-healing powers (and except that most proponents are latently or openly against vaccinations). And it is through these self-healing powers that the treatments in question cure anything and become a true panacea. When questioned what these incredible powers really are, most practitioners would (somewhat vaguely) name the immune system as the responsible mechanism. With this post, I intend to provide a short summary of the evidence on this issue:
Acupuncture: no good evidence to show stimulation of self-healing powers.
Aromatherapy: no good evidence to show stimulation of self-healing powers.
Bioresonance: no good evidence to show stimulation of self-healing powers.
Chiropractic: no good evidence to show stimulation of self-healing powers.
Detox: no good evidence to show stimulation of self-healing powers.
Energy healing: no good evidence to show stimulation of self-healing powers.
Feldenkrais: no good evidence to show stimulation of self-healing powers.
Gua sha: no good evidence to show stimulation of self-healing powers.
Herbal medicine: no good evidence to show stimulation of self-healing powers.
Homeopathy: no good evidence to show stimulation of self-healing powers.
Macrobiotics: no good evidence to show stimulation of self-healing powers.
Naturopathy: no good evidence to show stimulation of self-healing powers.
Osteopathy: no good evidence to show stimulation of self-healing powers.
Power bands: no good evidence to show stimulation of self-healing powers.
Reiki: no good evidence to show stimulation of self-healing powers.
Reflexology: no good evidence to show stimulation of self-healing powers.
Shiatsu: no good evidence to show stimulation of self-healing powers.
Tai chi: no good evidence to show stimulation of self-healing powers.
TCM: no good evidence to show stimulation of self-healing powers.
Vibrational therapy: no good evidence to show stimulation of self-healing powers.
Vaccinations: very good evidence to show stimulation of self-healing powers.
THE END
The literature on malpractice in medicine is huge: more than 33 000 articles listed in Medline. By contrast, the literature on malpractice in alternative medicine hardly exists. An exception is this recent article. I therefore thought I share it with you and provide a few comments:
START OF QUOTE
According to the (US) National Practitioner Data Bank, between September 1, 1990 and January 29, 2012, a total of 5,796 chiropractic medical malpractice reports were filed. Lawsuits with the highest payouts in any medical field are related to misdiagnosis, failure to diagnose and delayed diagnosis of a severe medical condition.
Common reasons for chiropractic malpractice lawsuits:
Chiropractor causes stroke: Numerous cases have been documented in which a patient suffers a stroke after getting his or her neck manipulated, or adjusted. Especially forceful rotation of the neck from side to side can overextend an artery that runs along the spine, which can result in a blockage of blood flow to the brain. Strokes are among the most serious medical conditions caused by chiropractic treatment, and can result in temporary or permanent paralysis, and even death.
Herniated disc following adjustment: Although many patients seek the medical attention of a chiropractor after they have experienced a herniated disc, chiropractors can actually be the cause of the problem. Usually a herniated disc is caused by wear and tear, but a sudden heavy strain, increased pressure to the lower back or twisting motions can cause a sudden herniated disc. The stress that chiropractors exercise in their adjustments have been known to be the root cause of some herniated discs.
Sexual misconduct: The American Chiropractic Association has assembled a code of ethics “based upon the acknowledgement that the social contract dictates the profession’s responsibilities to the patient, the public and the profession.” Sexual misconduct is among the top ten reasons that patients file lawsuits against chiropractors. Often, chiropractic practices are unfamiliar to many new patients and can be misinterpreted as inappropriate even though they are absolutely normal, so it is important that patients familiarize themselves with common chiropractic methods of healing.
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In this context, a study of chiropractic from Canada might be interesting. It highlights the conclusions from Canadian courts: informed consent is an ongoing process that cannot be entirely delegated to office personnel… A further study showed that valid consent procedures are either poorly understood or selectively implemented by chiropractors. Arguably, not obtaining informed consent amounts to malpractice.
In our book, this is what we conclude about informed consent by alternative therapists in general: Genuine informed consent is unattainable for most CAM modalities. This presents a serious and intractable ethical problem for CAM practitioners. Attempts to square this circle by watering down or redefining the criteria for informed consent are ethically indefensible. The concept of informed consent and its centrality in medical ethics therefore renders most CAM practice unacceptable. Conventional healthcare subscribes to the ethical principle ‘no consent, no treatment’: we are not aware of the existence of any good reasons to excuse CAM from this dictum.
I fear that, if we were to count the lack of informed consent by chiropractors (and other alternative practitioners) as malpractice, the numbers would be astronomical. Or, to put it differently, the often-cited relatively low malpractice rate in chiropractic is due to the omission of the vast majority of malpractice cases.
It has been reported that, between 1 January 2018 and 31 May 2018, there have been 587 laboratory confirmed measles cases in England. They were reported in most areas with London (213), the South East (128), West Midlands (81), South West (62), and Yorkshire/Humberside (53). Young people and adults who missed out on MMR vaccine when they were younger and some under-vaccinated communities have been particularly affected.
Public Health England (PHE) local health protection teams are working closely with the NHS and local authorities to raise awareness with health professionals and local communities. Anyone who is not sure if they are fully vaccinated should check with their GP practice who can advise them.
Dr Mary Ramsay, Head of Immunisation at PHE, said:
“The measles outbreaks we are currently seeing in England are linked to ongoing large outbreaks in Europe. The majority of cases we are seeing are in teenagers and young adults who missed out on their MMR vaccine when they were children. Anyone who missed out on their MMR vaccine in the past or are unsure if they had 2 doses should contact their GP practice to catch-up. This serves as an important reminder for parents to take up the offer of MMR vaccination for their children at 1 year of age and as a pre-school booster at 3 years and 4 months of age. We’d also encourage people to ensure they are up to date with their MMR vaccine before travelling to countries with ongoing measles outbreaks. The UK recently achieved WHO measles elimination status and so the overall risk of measles to the UK population is low, however, we will continue to see cases in unimmunised individuals and limited onward spread can occur in communities with low MMR coverage and in age groups with very close mixing.”
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And what has this to do with alternative medicine?
More than meets the eye, I fear.
The low vaccination rates are obviously related to Wakefield’s fraudulent notions of a link between MMR-vaccinations and autism. Such notions were keenly lapped up by the SCAM-community and are still being trumpeted into the ears of parents across the UK. As I have discussed many times, lay-homeopaths are at the forefront of this anti-vaccination campaign. But sadly the phenomenon is not confined to homeopaths nor to the UK; many alternative practitioners across the globe are advising their patients against vaccinations, e. g.:
- Governments take action to prevent vaccination-rates from falling
- Use of alternative medicine is associated with low vaccination rates
- Integrative medicine physicians tend to harbour anti-vaccination views
- Vaccination: chiropractors “espouse views which aren’t evidence based”
- Faith-healing as an alternative to vaccination?
- Recommending homeoprophylaxis is unethical, irresponsible and possibly even criminal
- Chiropractors are undermining public health
- CAM use is risk factor for the failure to immunize children
- Let’s be blunt: homeopathy is bogus – but homeoprophylaxis is worse, much worse!
- Are mothers being taught by homeopaths to become anti-vaxers?
- Some naturopaths are clearly a danger to public health
Considering these facts, I wish Dr Mary Ramsay, Head of Immunisation at PHE, would have had the courage to add to her statement: IT IS HIGH TIME THAT ALTERNATIVE PRACTITIONERS DO MORE THAN A MEEK LIP SERVICE TO THE FACT THAT VACCINATIONS SAVE LIVES.
In 2005, I published a systematic review of ophthalmic adverse effects after spinal manipulations. At the time, I found 14 case reports. Clinical symptoms and signs were diverse and included loss of vision, ophthalmoplegia, diplopia and Horner’s syndrome. The underlying mechanism was arterial wall dissection in most cases. The eventual outcome varied and often included permanent deficits. Causality was frequently deemed likely or certain.
I concluded that upper spinal manipulation is associated with ophthalmological adverse effects of unknown frequency. Ophthalmologists should be aware of its risks. Rigorous investigations must be conducted to establish reliable incidence figures.
Now a new article has emerged that throws more light on this issue:
A 46-year-old healthy male with a history of chronic musculoskeletal neck pain presented to the emergency department with left sided weakness after a syncopal episode. The patient had been treated with frequent chiropractic neck manipulations over the past seven years, with his last session one month prior to presentation. One week prior to presentation, the patient developed a new headache, anisocoria, and ptosis of his right upper eyelid. Computed tomography angiography (CTA) of the head and neck showed an internal carotid occlusion with right middle cerebral artery zone of ischemia, and tissue plasminogen activator (tPA) was administered. Subsequently, the patient experienced vision loss in his right eye. MRI and CTA were repeated, revealing a right ICA dissection from below the ophthalmic artery to the posterior communicating artery. On examination, vision in the right eye was no light perception (NLP) and the pupil was amaurotic. Fundus exam showed vascular attenuation, severe pallor of the optic nerve and retina, without a cherry red spot. A diagnosis of ophthalmic artery occlusion was made.
Inpatient workup revealed no stroke risk factors, and he was discharged on aspirin and clopidogrel therapy. Follow up imaging showed re-cannulation of the ICA, although vision remained NLP at outpatient evaluation the following month. Macular spectral domain optical coherence tomography (SDOCT) showed hyperreflectivity of the inner retina diffusely and of the outer retina and retinal pigment epithelium (RPE) centrally. Fluorescein angiography revealed patchy choroidal filling, delayed arterial filling, and macular nonperfusion. Three months after presentation, vision had improved to light perception, and remains stable at one year after the dissection.
Central retinal artery occlusion (CRAO) has been previously described after neck manipulation; however, these cases have been attributed to a dislodged embolic plaque rather than arterial dissection as in this case. Carotid artery dissection after neck manipulation is rare, although the exact incidence is unknown, and may be fatal.
The authors of this case report concluded that internal carotid artery dissection in this case was permanently devastating to the vision of a previously healthy young patient.
What follows is simple:
- upper spinal manipulations have no or very little proven benefit;
- they are associated with a finite risk;
- thus, their risk/benefit balance fails to be positive;
- consequently, upper spinal manipulations cannot be recommended as a treatment of any condition.
Systematic research on complaints about chiropractors, osteopaths, and physiotherapists is rare. We have often heard chiropractors claim that complaints against them are extremely rare events.
But is this true?
Two recent investigations might go some way towards answering this question.
The aim of the first investigation was to understand differences in the frequency and nature of formal complaints about Australian practitioners in these professions in order to inform improvements in professional regulation and education.
This retrospective cohort study analysed all formal complaints about all registered chiropractors, osteopaths, and physiotherapists in Australia lodged with health regulators between 2011 and 2016. Based on initial assessments by regulators, complaints were classified into 11 issues across three domains: performance, professional conduct, and health. Differences in complaint rate were assessed using incidence rate ratios. A multivariate negative binomial regression model was used to identify predictors of complaints among practitioners in these professions.
Patients and their relatives were the most common source of complaints about chiropractors, osteopaths and physiotherapists. Concerns about professional conduct accounted for more than half of the complaints about practitioners in these three professions. Regulatory outcome of complaints differed by profession. Male practitioners, those who were older than 65 years, and those who practised in metropolitan areas were at higher risk of complaint. The overall rate of complaints was higher for chiropractors than osteopaths and physiotherapists (29 vs. 10 vs. 5 complaints per 1000 practice years respectively, p < 0.001). Among chiropractors, 1% of practitioners received more than one complaint – they accounted for 36% of the complaints within their profession. Overall, nearly half of the complaints (47.7%) involved chiropractors, even though chiropractors make up less than one-sixth (13.9%) of the workforce across these three professions.
The authors concluded that their study demonstrates differences in the frequency of complaints by source, issue and outcome across the chiropractic, osteopathic and physiotherapy professions. Independent of profession, male sex and older age were significant risk factors for complaint in these professions. Chiropractors were at higher risk of being the subject of a complaint to their practitioner board compared with osteopaths and physiotherapists. These findings may assist regulatory boards, professional associations and universities in developing programs that avert patient dissatisfaction and harm and reduce the burden of complaints on practitioners.
The aim of the second study was to describe claims reported to the Danish Patient Compensation Association and the Norwegian System of Compensation to Patients related to chiropractic from 2004 to 2012.
All finalized compensation claims involving chiropractors reported to one of the two associations between 2004 and 2012 were assessed for age, gender, type of complaint, decisions and appeals. Descriptive statistics were used to describe the study population. The results show that 338 claims were registered in Denmark and Norway between 2004 and 2012 of which 300 were included in the analysis. 41 (13.7%) were approved for financial compensation. The most frequent complaints were worsening of symptoms following treatment (n = 91, 30.3%), alleged disk herniations (n = 57, 19%) and cases with delayed referral (n = 46, 15.3%). A total financial payment of €2,305,757 (median payment €7,730) were distributed among the forty-one cases with complaints relating to a few cases of cervical artery dissection (n = 11, 5.7%) accounting for 88.7% of the total amount.
The authors concluded that chiropractors in Denmark and Norway received approximately one compensation claim per 100.000 consultations. The approval rate was low across the majority of complaint categories and lower than the approval rates for general practioners and physiotherapists. Many claims can probably be prevented if chiropractors would prioritize informing patients about the normal course of their complaint and normal benign reactions to treatment.
In their discussion section the authors make the following comments: A particular concern after cervical SMT is dissection of the vertebral and carotid arteries. Seventeen claims concerning CAD were reported in this data, 14 in Denmark and three in Norway, and 11 of these were approved for financial compensation (64.7% approval rate) representing by far the highest approval rate across all complaint categories… chiropractors generally seem to receive more claims per consultation than GPs and physiotherapists, the approval rate is substantially lower and a similar trend is observed in Norway. However, it is also evident that approved claims within chiropractic bear a higher financial burden than their peers. These numbers are clearly highly influenced by the cases related to CAD. Several reasons might explain a higher complaint rate within chiropractic but this remains speculation and we do not have hard evidence supporting any of the following suggestions: (1) chiropractic treatment might be perceived as more aggressive than that of GPs and physiotherapists (2) maybe scepticism towards chiropractic among medical physicians and physiotherapists could encourage more patient complaints (3) a higher out-of-pocket expense for chiropractic services compared with GP and physiotherapist services might influence the higher number of complaints (4) chiropractors do not adequately inform patients about normal side effects and reactions and patients regard these as serious and relevant for compensation claims (5) chiropractors encourage patients to report AE more frequently than GPs and physiotherapists.
So, are complaints against chiropractors rarities?
I don’t think so.
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.
“In at least one article on chiropractic, Ernst has been shown to be fabricating data. I would not be surprised if he did the same thing with homeopathy. Ernst is a serial scientific liar.”
I saw this remarkable and charming Tweet yesterday. Its author is ‘Dr’ Avery Jenkins. Initially I was unaware of having had contact with him before; but when I checked my emails, I found this correspondence from August 2010:
Dr. Ernst:
Would you be so kind as to provide the full text of your article? Also, when would you be available for an interview for an upcoming feature article?
Thank you.
Avery L. Jenkins, D.C.
I put his title in inverted commas, because it turns out he is a chiropractor and not a medical doctor (but let’s not be petty!).
‘Dr’ Avery Jenkins runs a ‘Center for Alternative Medicine’ in the US: The Center has several features which set it apart from most other alternative medicine facilities, including the Center’s unique Dispensary. Stocked with over 300 herbs and supplements, the Dispensary’s wide range of natural remedies enables Dr. Jenkins to be the only doctor in Connecticut who provides custom herbal formulations for his patients. In our drug testing facility, we can provide on-site testing for drugs of abuse with immediate result reporting. Same-day appointments are available. Dr. Jenkins is also one of the few doctors in the state who has already undergone the federally-mandated training which will be necessary for all Department of Transportation Medical Examiners by 2014. Medical examinations for your Commercial Drivers License will take only 25 minutes, and Dr. Jenkins will provide you with all necessary paperwork.
The good ‘doctor’ also publishes a blog, and there I found a post from 2016 entirely dedicated to me. Here is an excerpt:
.. bias and hidden agendas come up in the research on alternative medicine and chiropractic in particular. Mostly this occurs in the form of journal articles using research that has been hand-crafted to make chiropractic spinal manipulation appear dangerous — when, in fact, you have a higher risk of serious injury while driving to your chiropractor’s office than you do of any treatment you receive while you’re there.
A case in point is the article, “Adverse effects of spinal manipulation: a systematic review,” authored by Edzard Ernst, and published in the Journal of the Royal Society of Medicine in 2007. Ernst concludes that, based on his review, “in the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.”
This conclusion throws up several red flags, beginning with the fact that it flies in the face of most of the already-published, extensive research which shows that chiropractic care is one of the safest interventions, and in fact, is safer than medical alternatives.
For example, an examination of injuries resulting from neck adjustments over a 10-year period found that they rarely, if ever, cause strokes, and lumbar adjustments by chiropractors have been deemed by one of the largest studies ever performed to be safer and more effective than medical treatment.
So the sudden appearance of this study claiming that chiropractic care should be stopped altogether seems a bit odd.
As it turns out, the data is odd as well.
In 2012, a researcher at Macquarie University in Australia, set out to replicate Ernst’s study. What he found was shocking.
This subsequent study stated that “a review of the original case reports and case series papers described by Ernst found numerous errors or inconsistencies,” including changing the sex and age of patients, misrepresenting patients’ response to adverse events, and claiming that interventions were performed by chiropractors, when no chiropractor was even involved in the case.
“In 11 cases of the 21…that Ernst reported as [spinal manipulative therapy] administered by chiropractors, it is unlikely that the person was a qualified chiropractor,” the review found.
What is interesting here is that Edzard Ernst is no rookie in academic publishing. In fact, he is a retired professor and founder of two medical journals. What are the odds that a man with this level of experience could overlook so many errors in his own data?
The likelihood of Ernst accidentally allowing so many errors into his article is extremely small. It is far more likely that Ernst selected, prepared, and presented the data to make it fit a predetermined conclusion.
So, Ernst’s article is either extremely poor science, or witheringly inept fraud. I’ll let the reader draw their own conclusion.
Interestingly enough, being called out on his antics has not stopped Ernst from disseminating equally ridiculous research in an unprofessional manner. Just a few days ago, Ernst frantically called attention to another alleged chiropractic mishap, this one resulting in a massive brain injury.
Not only has he not learned his lesson yet, Ernst tried the same old sleight of hand again. The brain injury, as it turns out, didn’t happen until a week after the “chiropractic” adjustment, making it highly unlikely, if not impossible, for the adjustment to have caused the injury in the first place. Secondly, the adjustment wasn’t even performed by a chiropractor. As the original paper points out, “cervical manipulation is still widely practiced in massage parlors and barbers in the Middle East.” The original article makes no claim that the neck adjustment (which couldn’t have caused the problem in the first place) was actually performed by a chiropractor.
It is truly a shame that fiction published by people like Ernst has had the effect of preventing many people from getting the care they need. I can only hope that someday the biomedical research community can shed its childish biases so that we all might be better served by their findings.
END OF QUOTE
Here I will not deal with the criticism a Australian chiropractor published in a chiro-journal 5 years after my 2007 article (which incidentally was not primarily about chiropractic but about spinal manipulation). Suffice to say that my article did NOT contain ‘fabricated’ data. A full re-analysis would be far too tedious, for my taste (especially as criticism of it has been discussed in all of 7 ‘letters to the editor’ soon after its publication)
- Adverse effects of spinal manipulation. [J R Soc Med. 2007]
- Adverse effects of spinal manipulation. [J R Soc Med. 2007]
- Adverse effects of spinal manipulation. [J R Soc Med. 2007]
- Adverse effects of spinal manipulation. [J R Soc Med. 2007]
- Adverse effects of spinal manipulation. [J R Soc Med. 2007]
- Adverse effects of spinal manipulation. [J R Soc Med. 2007]
- Adverse effects of spinal manipulation. [J R Soc Med. 2007]
I will, however, address ‘Dr’ Avery Jenkins’ second allegation related to my recent (‘frantic’) blog-post. I will do this by simply copying the abstract of the paper in question:
Background: Multivessel cervical dissection with cortical sparing is exceptional in clinical practice. Case presentation: A 55-year-old man presented with acute-onset neck pain with associated sudden onset right-sided hemiparesis and dysphasia after chiropractic* manipulation for chronic neck pain. Results and Discussion: Magnetic resonance imaging revealed bilateral internal carotid artery dissection and left extracranial vertebral artery dissection with bilateral anterior cerebral artery territory infarctions and large cortical-sparing left middle cerebral artery infarction. This suggests the presence of functionally patent and interconnecting leptomeningeal anastomoses between cerebral arteries, which may provide sufficient blood flow to salvage penumbral regions when a supplying artery is occluded. Conclusion: Chiropractic* cervical manipulation can result in catastrophic vascular lesions preventable if these practices are limited to highly specialized personnel under very specific situations.
*my emphasis
With this, I rest my case.
The only question to be answered now is this: TO SUE OR NOT TO SUE?
What do you think?
