I would warn every parent who thinks that taking their child to a chiropractor is a good idea. For this, I have three main reasons:
- Chiropractic has not been shown to be effective for any paediatric condition.
- Chiropractors often advise parents against vaccinating their children.
- Chiropractic spinal manipulations can cause harm to kids.
The latter point seems to be confirmed by a recent PhD thesis of which so far only one short report is available. Here are the relevant bits of information from it:
Katie Pohlman has successfully defended her PhD thesis, which focused on the assessment of safety in pediatric manual therapy. As a clinical research scientist at Parker University, Dallas, Texas, she identified a lack of prospective patient safety research within the chiropractic population in general and investigated this deficit in the paediatric population in particular.
Pohlman used a cross-sectional survey to assess the barriers and facilitators for participation in a patient safety reporting system. At the same time, she also conducted a randomized controlled trial comparing the quantity and quality of adverse event reports in children under 14 years receiving chiropractic care.
The RCT recruited 69 chiropractors and found adverse events reported in 8.8% and 0.1% of active and passive surveillance groups respectively. Of the adverse events reported, 56% were considered mild, 26% were moderate and 18% were severe. The frequency of adverse events was more common than previously thought.
This last sentence from the report is somewhat puzzling. Our systematic review of the risks of spinal manipulation showed that data from prospective studies suggest that minor, transient adverse events occur in approximately half of all patients receiving spinal manipulation. The most common serious adverse events are vertebrobasilar accidents, disk herniation, and cauda equina syndrome. Estimates of the incidence of serious complications range from 1 per 2 million manipulations to 1 per 400,000. Given the popularity of spinal manipulation, its safety requires rigorous investigation.
The 8.8% reported by Pohlman are therefore not even one fifth of the average incidence figure reported previously in all age groups.
What could be the explanation for this discrepancy?
There are, of course, several possibilities, including the fact that infants cannot tell the clinician when their pain has increased. However, the most likely one, in my view, lies in the fact that RCTs are wholly inadequate for investigating risks because they typically include far too few patients to generate reliable incidence figures about adverse events. More importantly, clinicians included in such studies are self-selected (and thus particularly responsible/cautious) and are bound to behave most carefully while being part of a clinical trial. Therefore it seems possible – I would speculate even likely – that the 8.8% reported by Pohlman is unrealistically low.
Having said that, I do feel that the research by Kathie Pohlman is a step in the right direction and I do applaud her initiative.
The 2018 World Federation of Chiropractic ACC Education Conference was held on 24-27 October in London. It resulted in several consensus statements developed by the attendees. I happen to know this from a short report that has just been published; it can be found here.
Of the 10 points made in this consensus, I find only the following noteworthy:
“Chiropractic education programs have an ethical obligation to support an evidence-based teaching and learning environment.”
Perhaps it is me – English is not my first language – but I find the phraseology used in this sentence strangely complicated and confusing. I have been a teacher of medical students for most of my life, but I am not sure what an ‘evidence-based teaching and learning environment’ is. I know what ‘evidence-based’ means, of course. However, what exactly is:
- a teaching environment?
- a learning environment?
- and how does ‘evidence-based’ apply to either of the two?
Is there evidence that some environments are better suited than others for teaching?
Is there evidence that some environments are better suited than others for learning?
I suppose the answer must be YES!
The environment, i. e. the space and conditions in which teaching and learning happen should, for instance, be/include:
- not cramped,
- not too cold,
- not too hot,
- equipped with ergometric chairs and desks,
- there should be visual aids,
- access to computers,
- a library,
- good mentoring and support,
So, the consensus of the education conference wanted to optimise the environmental conditions of teaching and learning for chiropractic lecturers and students? Most laudable, I must say!
But still, it seems like a missed opportunity for an ‘Education Conference’ not to have stated something about the content of teaching and learning. Personally, I find it a pity that they did not state: Chiropractic education programs have an ethical obligation to be evidence-based.
Or is that what they really wanted to say?
Naaahh … come to think of it … they cannot possibly make such a demand.
Because, in this case, they would have to teach students not to become chiropractors.
Slowly, I seem to be turning into a masochist! Yes, I sometimes read publications like ‘HOMEOPATHY 360’. It carries articles that are enragingly ill-informed. But in my defence, I might say that some are truly funny. Here is the abstract of one that I found outstanding in that category:
The article explains about Gangrene and its associated amputations which is a clinically challenging condition, but Homeopathy offers therapy options. The case presented herein, details about how the Homeopathic treatment helped in the prevention of amputation of a body part. Homeopathy stimulates the body’s ability to heal through its immune mechanisms; consequently, it achieves wound healing and establishes circulation to the gangrenous part. Instead of focusing on the local phenomena of gangrene pathology, treatment focuses on the general indications of the immune system, stressing the important role of the immune system as a whole. The aim was to show, through case reports, that Homeopathic therapy can treat gangrene thus preventing amputation of the gangrenous part, and hence has a strong substitution for consideration in treating gangrene.
The paper itself offers no less than 13 different homeopathic treatments for gangrene:
- Arsenicum album– Medicine for senile gangrene;gangrene accompanied by foetid diarrhoea; ulcers extremely painful with elevated edges, better by warmth and aggravation from cold; great weakness and emaciation.
- Bromium – Hospital gangrene; cancerous ulcers on face; stony hard swelling of glands of lower jaw and throat.
- Carbo vegetabilis – Senile and humid gangrene in the persons who are cachectic in appearance; great exhaustion of vital powers; marked prostration; foul smell of secretions; indolent ulcers, burning pain; tendency to gangrene of the margins; varicose ulcers.
- Bothrops– Gangrene; swollen, livid, cold with hemorrhagic infiltration; malignant erysipelas.
- Echinacea– Enlarged lymphatics; old tibial ulcers; gangrene; recurrent boils; carbuncles.
- Lachesis– Gangrenous ulcers; gangrene after injury; bluish or black looking blisters; vesicles appearing here and there, violent itching and burning; swelling and inflammation of the parts; itching pain and painful spots appearing after rubbing.
- Crotalus Horridus– Gangrene, skin separated from muscles by a foetid fluid; traumatic gangrene; old scars open again.
- Secale cornatum– Pustules on the arms and legs, with tendency to gangrene; in cachectic, scrawny females with rough skin; skin shriveled, numb; mottled dusky-blue tinge; blue color of skin; dry gangrene, developing slowly; varicose ulcers; boils, small, painful with green contents; skin feels too cold to touch yet covering is not tolerated. Great aversion to heat;formication under skin.
- Anthracinum– Gangrene; cellular tissues swollen and oedematous; gangrenous parotitis; septicemia; ulceration, and sloughing and intolerable burning.
- Cantharis – Tendency to gangrene; vesicular eruptions; burns, scalds, with burning and itching; erysipelas, vesicular type, with marked restlessness.
- Mercurius– Gangrene of the lips, cheeks and gums; inflammation and swelling of the glands of neck; pains aggravated by hot or cold applications.
- Sulphuric acid– Traumatic gangrene; haemorrhages from wounds; dark pustules; blue spots like suggillations; bedsores.
- Phosphoric acid– Medicine for senile gangrene. Gunpowder, calendula are also best medicines.
But the best of all must be the article’s conclusion: “Homeopathy is the best medicine for gangrene.”
I know, there are many people who will not be able to find this funny, particularly patients who suffer from gangrene and are offered homeopathy as a cure. This could easily kill the person – not just kill, but kill very painfully. Gangrene is the death of tissue in part of the body, says the naïve little caption. What it does not say is that it is in all likelihood also the death of the patient who is treated purely with homeopathy.
And what about the notion that homeopathy stimulates the body’s ability to heal through its immune mechanisms?
Or the assumption that it might establish circulation to the gangrenous part?
Or the claim that through case reports one can show the effectiveness of an intervention?
Or the notion that any of the 13 homeopathic remedies have a place in the treatment of gangrene?
ALL OF THIS IS TOTALLY BONKERS!
Not only that, it is highly dangerous!
Since many years, I am trying my best to warn people of charlatans who promise bogus cures. Sadly it does not seem to stop the charlatans. This makes me feel rather helpless at times. And it is in those moments that I decide to look at from a different angle. That’s when I try to see the funny side of quacks who defy everything we know about healthcare and just keep on lying to themselves and their victims.
Lumbar spinal stenosis (LSS) is a common reason for spine surgery. Several non-surgical LSS treatment options are also available, but their effectiveness remains unproven. The objective of this study was to explore the comparative clinical effectiveness of three non-surgical interventions for patients with LSS:
- medical care,
- group exercise,
- individualised exercise plus manual therapy.
All interventions were delivered during 6 weeks with follow-up at 2 months and 6 months at an outpatient research clinic. Patients older than 60 years with LSS were recruited from the general public. Eligibility required anatomical evidence of central canal and/or lateral recess stenosis (magnetic resonance imaging/computed tomography) and clinical symptoms associated with LSS (neurogenic claudication; less symptoms with flexion). Analysis was intention to treat.
Medical care consisted of medications and/or epidural injections provided by a physiatrist. Group exercise classes were supervised by fitness instructors. Manual therapy/individualized exercise consisted of spinal mobilization, stretches, and strength training provided by chiropractors and physical therapists. The primary outcomes were between-group differences at 2 months in self-reported symptoms and physical function measured by the Swiss Spinal Stenosis questionnaire (score range, 12-55) and a measure of walking capacity using the self-paced walking test (meters walked for 0 to 30 minutes).
A total of 259 participants were allocated to medical care (n = 88), group exercise (n = 84), or manual therapy/individualized exercise (n = 87). Adjusted between-group analyses at 2 months showed manual therapy/individualized exercise had greater improvement of symptoms and physical function compared with medical care or group exercise. Manual therapy/individualized exercise had a greater proportion of responders (≥30% improvement) in symptoms and physical function (20%) and walking capacity (65.3%) at 2 months compared with medical care (7.6% and 48.7%, respectively) or group exercise (3.0% and 46.2%, respectively). At 6 months, there were no between-group differences in mean outcome scores or responder rates.
The authors concluded that a combination of manual therapy/individualized exercise provides greater short-term improvement in symptoms and physical function and walking capacity than medical care or group exercises, although all 3 interventions were associated with improvements in long-term walking capacity.
In many ways, this is a fairly rigorous study; in one important way, however, it is odd. One can easily see why one group received the usual standard care (except perhaps for the fact that standard medical care should also include exercise). I also understand why one group attended group exercise. Yet, I fail to see the logic in the third intervention, individualised exercise plus manual therapy.
Individualised exercise is likely to be superior to group exercise. If the researchers wanted to test this hypothesis, they should not have added the manual therapy. If they wanted to find out whether manual therapy is better that the other two treatments, they should not have added individualised exercise. As it stands, they cannot claim that either manual therapy or individualised exercise are effective (yet, I am sure that the chiropractic fraternity will claim that this study shows their treatment to be indicated for LSS [three of the authors are chiropractors and the 1st author seems to have a commercial interest in the matter!]).
Manual therapy procedures used in this trial included:
- lumbar distraction mobilization,
- hip joint mobilization,
- side posture lumbar/sacroiliac joint mobilization,
- and neural mobilization.
Is there any good reason to assume that these interventions work for LSS? I doubt it!
And this is what makes the new study odd, in my view. Assuming I am correct in speculating that individualised exercise is better than group exercise, the trial would have yielded a similarly positive result, if the researchers had offered, instead of the manual therapy, a packet of cigarettes, a cup of tea, a chocolate bar, or swinging a dead cat. In other words, if someone had wanted to make a useless therapy appear to be effective, they could not have chosen a better trial design.
And why do I find such studies objectionable?
Mainly because they deliberately mislead many of us. In the present case, many non-critical observers might conclude that manual therapy is effective for LSS. Yet, the truth could well be that it is useless or even harmful (assuming that the effect size of individualised exercise is large, adding a harmful therapy would still render the combination effective). To put it bluntly, such trials
- could harm patients,
- might waste money,
- and hinder progress.
I came across an embarrassingly poor and uncritical article that essentially seemed to promote a London-based clinic specialised in giving vitamins intravenously. Its website shows the full range of options on offer and it even lists the eye-watering prices they command. Reading this information, my amazement became considerable and I decided to share some of it with you.
Possibly the most remarkable of all the treatments on offer is this one (the following are quotes from the clinic’s website):
Stemcellation injections or placenta lucchini (sheep placenta) treatments are delivered intravenously (via IV), although intramuscular (IM) administration is also possible. Stem cells are reported to possess regenerative biological properties.
We offer two types of Stemcellation injections: a non-vegetarian option and a vegetarian-friendly option. Please enquire for further details.
Alongside placenta lucchini, Stemcellation injections at Vitamin Injections London contain a range of other potent active ingredients, including: physiologically active carbohydrate, nucleic acid, epithelial growth factor, amino acids, hydrolysed collagen, concentrated bioprotein and stem cells.
Please visit our Vitamin 101 section to learn more about the ingredients in Stemcellation sheep placenta injections.
Renowned for their powerful regenerating properties, Stemcellation injections can stimulate collagen production as well as:
- Remedy cosmetic problems such as wrinkles, discolouration, pigmentation, eye bags and uneven skin tone;
- Can be undertaken by those who are interested in maintaining their physical activity levels;
- Can be undertaken alongside other IV/IM injections.
Vitamin Injections London is headed by skilled IV/IM Medical Aesthetician and Skin Specialist Bianca Estelle. Our skilled IV/IM practitioners will conduct a full review of your medical history and advise you regarding your suitability for Stemcellation injections.
END OF QUOTES
The only Medline-listed paper I was able to locate on the subject of placenta lucchini injections was from 1962 and did not substantiate any of the above claims. In my view, all of this begs many questions; here are just seven that spring into my mind:
- Is there any evidence at all that any of the intravenous injections/infusions offered at this clinic are effective for any condition other than acute vitamin deficiencies (which are, of course, extremely rare these days)?
- Would the staff be adequately trained to diagnose such cases?
- How do they justify the price tags for their treatments?
- What is a ‘medical aesthetician’ and a ‘skin specialist’?
- Is it at all legal for ‘medical aestheticians’ and ‘skin specialists’ (apparently without medical qualifications) to give intravenous injections and infusions?
- How many customers have suffered severe allergic reactions after placenta lucchini (or other) treatments?
- Is the clinic equipped and its staff adequately trained to deal with medical emergencies?
These are not rhetorical questions; I genuinely do not know the answers. Therefore, I would be obliged, if you could answer them for me, in case you know them.
My last post was rather depressive, and I certainly do not want my readers to be under the weather when they go into 2019. For this last post of 2018, I have therefore selected 20 events which gave me hope that perhaps we – those who prefer rationality to nonsense – are making progress.
- It has been reported that New Brunswick judge ruled this week that Canadian naturopaths — pseudoscience purveyors who promote a variety of “alternative medicines” like homeopathy, herbs, detoxes, and acupuncture — cannot legally call themselves “medically trained.”
- The Spanish Ministries of Health and Sciences announced their ‘Health Protection Plan against Pseudotherapies’.
- The medical school of Vienna axed their courses in homeopathy.
- A most comprehensive review of homeopathy concluded that the effects of homeopathy do not differ from those of placebo.
- The UK Pharmaceutical Society has stated that it does not endorse homeopathy and that pharmacists must advise patients considering a homeopathic product about their lack of efficacy beyond that of a placebo.
- A top medical journal has retracted a dodgy meta-analysis of acupuncture.
- A prominent BMJ columnist wrote : Many people seek to make money from those who don’t understand science. Doctors should call out bollocksology when they see it.
- Pharmacare and Bioglan received a ‘Stonky’ for its over-the-counter Melatonin Homeopathic Sleep Formula.
- The Governing Body of Bristol, North Somerset and South Gloucestershire (BNSSG) Clinical Commissioning Group (CCG) approved changes that mean NHS funded homeopathy will only be available in exceptional circumstances in the area.
- Health ministers of all German counties have decided that they will start reforming the profession of the Heilpraktiker, the German non-medically trained alternative practitioners.
- The NHS chief, Simon Stevens was quoted saying: There is no robust evidence to support homeopathy which is at best a placebo and a misuse of scarce NHS funds.
- A systematic review concluded that there is no evidence in the literature of an effect of chiropractic treatment in the scope of primary prevention or early secondary prevention for disease in general. Chiropractors have to assume their role as evidence-based clinicians and the leaders of the profession must accept that it is harmful to the profession to imply a public health importance in relation to the prevention of such diseases through manipulative therapy/chiropractic treatment.
- A Cochrane review did not show any benefit of homeopathic medicinal products compared to placebo on recurrence of acute respiratory tract infections or cure rates in children.
- The French minister of health stated that ‘the French are very attached [to homeopathy]; it’s probably a placebo effect. If it can prevent the use of toxic medicine, I think that we all win. I does not hurt.
- The Australian Acupuncture and Chinese Medicine Association retracted false accusation against me about their assumption that I had undeclared conflicts of interest.
- The ‘Daily Telegraph‘ published the following statement after misquoting me: Emeritus Professor Edzard Ernst, Britain’s first professor of complementary medicine at Exeter University said that doctors should make it clear to patients that they could not be taking herbal remedies alongside drugs. Prof Ernst said there was no good evidence that they work and that doctors were ‘contributing to disinformation’ by turning a blind eye to the practice.
- A comprehensive overview of the therapeutic options for chronic low back pain showed that chiropractic is not any better than over-the-counter painkillers or exercise, and that patients need to take precautions when seeking out a chiropractor.
Hold on, you promised 20, but these are just 17!!!, I hear my attentive readers mutter.
Yet, this should not depress us. On the contrary, let’s see it as a challenge to get on with out work of fighting for good evidence, ethical standards, rationality and critical thinking.In this spirit, I wish you all a very good, healthy and productive year 2019.
Naturopathy is an eclectic system of health care that uses elements of alternative and conventional medicine to support and enhance self-healing processes. Naturopaths employ treatments based on therapeutic options that are thought of as natural, e. g. naturally occurring substances such as herbs, as well as water, exercise, diet, fresh air, pressure, heat and cold – but occasionally also acupuncture, homeopathy and manual therapies.
Naturopathy is steeped in the obsolete concept of vitalism which is the belief that living organisms are fundamentally different from non-living entities because they contain some non-physical element or are governed by different principles than are inanimate things. Naturopaths claim that they are guided by a unique set of principles that recognize the body’s innate healing capacity, emphasize disease prevention, and encourage individual responsibility to obtain optimal health. They also state that naturopathic physicians (NDs) are trained as primary care physicians in 4-year, accredited doctoral-level naturopathic medical schools.
However, applied to English-speaking countries (in Germany, a doctor of naturopathy is a physician who has a conventional medical degree), such opinions seem little more than wishful thinking. It has been reported that New Brunswick judge ruled this week that Canadian naturopaths — pseudoscience purveyors who promote a variety of “alternative medicines” like homeopathy, herbs, detoxes, and acupuncture — cannot legally call themselves “medically trained.”
The lawsuit was filed because actual physicians were frustrated that fake doctors were using terms like “medical practitioner” and saying they worked at a “family practice.” This conveyed the false idea that naturopaths were qualified at the same level as real doctors.
The argument from naturopaths was that they weren’t misleading anyone. “There’s not even the slightest hint of evidence that anyone has been misled — or worse, harmed,” [attorney Nathalie Godbout] said. “This mythical patient that has to be protected by naturopathic doctors — I haven’t met them yet.”
However, Justice Hugh McLellan wasn’t buying it. He said the justification for naturopaths using terms such as “doctor” and “family physician” are based on the assumption that “people are attuned to the meaning of words like “naturopathy.” Many patients might read a website or a Facebook ad out of context, he said, and fail to pick up on the difference between “a doctor listing his or her qualifications as ‘Dr. So-and-So, B.Sc., MD,’ as opposed to the listing that might include ‘B.Sc., ND [naturopathic practitioner].’”
“I see a risk here,” McLellan said, “that the words … could, in fact, imply or be designed to lead the public to believe these various naturopaths are entitled to practise medicine.”
Britt Marie Hermes, a former naturopath who now warns people about the shortcomings of the profession, said she was thrilled with the judge’s ruling: “This is a very encouraging step in the right direction toward ensuring public safety. Naturopaths are not doctors. The onus should not be on patients to vet the credentials and competency of someone holding themselves out to be a medically trained physician. Now, patients will have an easier time separating truly medically qualified physicians from naturopathic practitioners. Bravo New Brunswick!”
In view of the many horror-stories that emerge about naturopathy, I am inclined to agree with Britt:
- Naturopaths tend to advise against vaccination.
- Some naturopaths advocate CEASE therapy.
- Many naturopaths use bogus treatments such as homeopathy.
- Some naturopaths claim to able to treat cancer.
- This has resulted in fatalities.
In the context of healthcare the title ‘doctor’ or ‘physician’ must be reserved to those who have a conventional medical degree. Anything else means misleading the public to an unacceptable degree, in my view.
A few weeks ago, I was interviewed by a journalist who wanted to publish the result in a magazine. He now informed me that his editor decided against it, and the interview thus remained unpublished. I have the journalist’s permission to publish it here. The journalist who, in my view, was well-prepared (much better than most), prefers to remain unnamed.
Q: How would you describe yourself?
A: I am a researcher of alternative medicine.
Q: Not a critic of alternative medicine?
A: Primarily, I am a researcher; after all, I have published more Medline-listed research papers on the subject than anyone else on the planet.
Q: You are retired since a few years; why do you carry on working?
A: Mainly because I see a need for a critical voice amongst all the false and often dangerous claims made by proponents of alternative medicine. But also because I enjoy what I am doing. Since I retired, I can focus on the activities I like. There is nobody to tell me what to do and what not to do; the latter happened far too often when I was still head of my research unit.
Q: Fine, but I still do not quite understand what drives you. Who is motivating you to criticise alternative medicine?
A: Nobody. Some people claim I am paid for my current activities. This is not true. My blog actually costs me money. My books never return enough royalties to break even, considering the time they take to write. And for most of my lectures I don’t charge a penny.
Q: There are people who find this hard to believe.
A: I know. This just shows how money-orientated they are. Do they want me to publish my tax returns?
Q: Sorry, but I still don’t understand your motivation.
A: I guess what motivates me is a sense of responsibility, a somewhat naïve determination to do something good as a physician. I am one of the only – perhaps even THE only – scientist who has researched alternative medicine extensively and who is not a promoter of bogus therapies but voices criticism about them. There are several other prominent and excellent critics of alternative medicine, of course, but they all come ‘from the outside’. I come from the inside of the alternative medicine business. This probably gives me a special understanding of this field. In any case, I feel the responsibility to counter-balance all the nonsense that is being published on a daily basis.
Q: What’s your ultimate aim?
A: I want to create progress through educating people to think more critically.
Q: Which alternative medicine do you hate most?
A: I do not hate any of them. In fact, I still have more sympathy for them than might be apparent. For my blog, for instance, I constantly search for new research papers that are rigorous and show a positive result. The trouble is, there are so very few of those articles. But when I find one, I am delighted to report about it. No, I do not hate or despise any alternative medicine; I am in favour of good science, and I get irritated by poor research. And yes, I do dislike false claims that potentially harm consumers. And yes, I do dislike it when chiropractors or other charlatans defraud consumers by taking their money for endless series of useless interventions.
Q: I noticed you go on about the risks of alternative medicine. But surely, they are small compared to the risks of conventional healthcare, aren’t they?
A: That’s a big topic. To make it simple: alternative medicine is usually portrayed as risk-free. The truth, however, is that there are numerous risks of direct and indirect harm; the latter is usually much more important than the former. Crucially, the risk-free image is incongruent with reality. I want to redress this incongruence. And as to conventional medicine: sure, it can be much more harmful. But one always has to see this in relation to the proven benefit. Chemotherapy, for instance, can kill a cancer patient, but more likely it saves her life. Homeopathic remedies cannot kill you, but employed as an alternative to an effective cancer treatment, homeopathy will certainly kill you.
Q: Homeopathy seems to be your particular hobby horse.
A: Perhaps. This is because it exemplifies alternative medicine in several ways, and because I started my alternative ‘career’ in a homeopathic hospital, all those years ago.
Q: In what way is homeopathy exemplary?
A: Its axioms are implausible, like those of many other alternative modalities. The clinical evidence fails to support the claims, like with so many alternative therapies. And it is seemingly safe, yet can do a lot of harm, like so many other treatments.
Q: You have no qualification in homeopathy, is that right?
A: No, I have no such qualifications. And I never said so. When I want to tease homeopaths a little, I state that I am a trained homeopath; and that is entirely correct.
Q: In several countries, homeopathy has taken spectacular hits recently. Is that your doing?
A: No, I don’t think so. But I do hope that my work has inspired the many dedicated activists who are currently protesting against the reimbursement of homeopathy by the public purse in the UK, Germany, France, Spain, etc.
Q: You often refer to medical ethics; why is that?
A: Because, in the final analysis, many of the questions we already discussed are really ethical issues. And in alternative medicine, few people have so far given the ethical dimensions any consideration. I think ethics are central to alternative medicine, so much so that I co-authored an entire book on this topic this year.
Q: Any plans for the future?
Q: Can you tell me more?
A: I will publish another book in 2019 with Springer. It will be a critical evaluation of precisely 150 different alternative modalities. I am thinking of writing yet another book, but have not yet found a literary agent who wants to take me on. I have been offered a new professorship at a private University in Vienna, and am hesitant whether to accept or not. I have been invited to give a few lectures in 2019 and hope to receive more invitations. Last not least, I work almost every day on my blog.
Q: More than enough for a retiree, it seems. Thank you for your time.
A: My pleasure.
On their website, the UK ‘ROYAL COLLEGE OF CHIROPRACTORS (RCC) published a short statement regarding the safety of chiropractic. Here it is in full:
Experiencing mild or moderate adverse effects after manual therapy, such as soreness or stiffness, is relatively common, affecting up to 50% of patients. However, such ‘benign effects’ are a normal outcome and are not unique to chiropractic care.
Cases of serious adverse events, including spinal or neurological problems and strokes caused by damage to arteries in the neck, have been associated with spinal manipulation. Such events are rare with estimates ranging from 1 per 2 million manipulations to 13 per 10,000 patients; furthermore, due to the nature of the underlying evidence in relation to such events (case reports, retrospective surveys and case-control studies), it is very difficult to confirm causation (Swait and Finch, 2017).
For example, while an association between stroke caused by vertebral artery damage or ‘dissection’ (VAD) and chiropractor visits has been reported in a few case-control studies, the risk of stoke has been found to be similar after seeing a primary care physician (medical doctor). Because patients with VAD commonly present with neck pain, it is possible they seek therapy for this symptom from a range of practitioners, including chiropractors, and that the VAD has occurred spontaneously, or from some other cause, beforehand (Biller et al, 2014). This highlights the importance of ensuring careful screening for known neck artery stroke risk factors, or signs or symptoms that there is an ongoing problem, is performed prior to manual treatment of patients (Swait and Finch, 2017). Chiropractors are well trained to do this on a routine basis, and to urgently refer patients if necessary.
END OF QUOTE
The statement reads well but it might not be entirely free from conflicts of interest. Yet, in the name of accuracy, completeness and truthfulness, I take the liberty of making a few slight alterations. Here is my revised version:
Experiencing mild or moderate adverse effects after chiropractic spinal manipulations, such as pain or stiffness (usually lasting 1-3 days and strong enough to impair patients’ quality of life), is very common. In fact, it affects around 50% of all patients.
Cases of serious adverse events, including spinal or neurological problems and strokes often caused by damage to arteries in the neck, have been reported after spinal manipulation. Such events are probably not frequent (several hundred are on record including about 100 fatalities). But, as we have never established proper surveillance systems, nobody can tell how often they occur. Furthermore, due to our reluctance of introducing such surveillance, some of us are able to question causality.
An association between stroke caused by vertebral artery damage or ‘dissection’ (VAD) and chiropractic spinal manipulation has been reported in about 20 independent investigations. Yet one much-criticised case-control study found the risk of stoke to be similar after seeing a primary care physician (medical doctor). Because patients with VAD commonly have neck pain, it is possible they seek therapy for this symptom from chiropractors, and that the VAD has occurred spontaneously, or from some other cause, beforehand (Biller et al, 2014). Ensuring careful screening for known neck artery stroke risk factors, or signs that there is an ongoing problem would therefore be important (Swait and Finch, 2017). Sadly, no reliable screening tests exist, and neck pain (the symptom that might be indicative of VAD) continues to be one of the conditions most frequently treated by chiropractors.
I do not expect the RCC to adopt my improved version. In case I am wrong, let me state this: I am entirely free of conflicts of interest and will not charge a fee for my revision. In the interest of advancing public health, I herewith offer it for free.
The Spanish Ministries of Health and Sciences have announced their ‘Health Protection Plan against Pseudotherapies’. Very wisely, they have included chiropractic under this umbrella. To a large degree, this is the result of Spanish sceptics pointing out that alternative therapies are a danger to public health, helped perhaps a tiny bit also by the publication of two of my books (see here and here) in Spanish. Unsurprisingly, such delelopments alarm Spanish chiropractors who fear for their livelihoods. A quickly-written statement of the AEQ (Spanish Chiropractic Association) is aimed at averting the blow. It makes the following 11 points (my comments are below):
1. The World Health Organization (WHO) defines chiropractic as a healthcare profession. It is independent of any other health profession and it is neither a therapy nor a pseudotherapy.
2. Chiropractic is statutorily recognised as a healthcare profession in many European countries including Portugal, France, Italy, Switzerland, Belgium, Denmark, Sweden, Norway and the United Kingdom10, as well as in the USA, Canada and Australia, to name a few.
3. Chiropractic members of the AEQ undergo university-level training of at least 5 years full-time (300 ECTS points). Chiropractic training is offered within prestigious institutions such as the Medical Colleges of the University of Zurich and the University of Southern Denmark.
4. Chiropractors are spinal health care experts. Chiropractors practice evidence-based, patient-centred conservative interventions, which include spinal manipulation, exercise prescription, patient education and lifestyle advice.
5. The use of these interventions for the treatment of spine-related disorders is consistent with guidelines and is supported by high quality scientific evidence, including multiple systematic reviews undertaken by the prestigious Cochrane collaboration15, 16, 17.
6. The Global Burden of Disease study shows that spinal disorders are the leading cause of years lived with disability worldwide, exceeding depression, breast cancer and diabetes.
7. Interventions used by chiropractors are recommended in the 2018 Low Back Pain series of articles published in The Lancet and clinical practice guidelines from Denmark, Canada, the European Spine Journal, American College of Physicians and the Global Spine Care Initiative.
8. The AEQ supports and promotes scientific research, providing funding and resources for the development of high quality research in collaboration with institutions of high repute, such as Fundación Jiménez Díaz and the University of Alcalá de Henares.
9. The AEQ strenuously promotes among its members the practice of evidence-based, patient-centred care, consistent with a biopsychosocial model of health.
10. The AEQ demands the highest standards of practice and professional ethics, by implementing among its members the Quality Standard UNE-EN 16224 “Healthcare provision by chiropractors”, issued by the European Committee of Normalisation and ratified by AENOR.
11. The AEQ urges the Spanish Government to regulate chiropractic as a healthcare profession. Without such legislation, citizens of Spain cannot be assured that they are protected from unqualified practitioners and will continue to face legal uncertainties and barriers to access an essential, high-quality, evidence-based healthcare service.
END OF QUOTE
I think that some comments might be in order (they follow the numbering of the AEQ):
- The WHO is the last organisation I would consult for information on alternative medicine; during recent years, they have published mainly nonsense on this subject. How about asking the inventor of chiropractic? D.D. Palmer defined it as “a science of healing without drugs.” Chiropractors nowadays prefer to be defined as a profession which has the advantage that one cannot easily pin them down for doing mainly spinal manipulation; if one does, they indignantly respond “but we also use many other interventions, like life-style advice, for instance, and nobody can claim this to be nonsense” (see also point 4 below).
- Perfect use of a classical fallacy: appeal to authority.
- Appeal to authority, plus ignorance of the fact that teaching nonsense even at the highest level must result in nonsense.
- This is an ingenious mix of misleading arguments and lies: most chiros pride themselves of treating also non-spinal conditions. Very few interventions used by chiros are evidence-based. Exercise prescription, patient education and lifestyle advice are hardy typical for chiros and can all be obtained more authoratively from other healthcare professionals.
- Plenty of porkies here too. For instance, the AEQ cite three Cochrane reviews. The first concluded that high-quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. The second stated that combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute/subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions. And the third concluded that, although support can be found for use of thoracic manipulation versus control for neck pain, function and QoL, results for cervical manipulation and mobilisation versus control are few and diverse. Publication bias cannot be ruled out. Research designed to protect against various biases is needed. Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilisation and comparing mobilisation or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices. Hardly the positive endorsement implied by the AEQ!
- Yes, but that is not an argument for chiropractic; in fact, it’s another fallacy.
- Did they forget the many guidelines, institutions and articles that do NOT recommend chiropractic?
- I believe the cigarette industry also sponsors research; should we therefore all start smoking?
- I truly doubt that the AEQ strenuously promotes among its members the practice of evidence-based healthcare; if they did, they would have to discourage spinal manipulation!
- The ‘highest standards of practice and professional ethics’ are clearly not compatible with chiropractors’ use of spinal manipulation. In our recent book, we explained in full detail why this is so.
- An essential, high-quality, evidence-based healthcare service? Chiropractic is certainly not essential, rarely high-quality, and clearly not evidence-based.
Nice try AEQ.
But not good enough, I am afraid.