spinal manipulation
I will state my position up front: THERE IS NO CHILDHOOD CONDITION FOR WHICH CHIROPRACTIC SPINAL MANIPULATION GENERATES MORE GOOD THAN HARM. What is more, I have published evidence (published here, here, here, and here, for instance) to support this statement. If you disagree with it, this is the place and time to do so – and please don’t forget to cite the evidence that supports your statements.
Given that there is very little reliable evidence in this area, I find it surprising that so many chiropractors continue to treat kids. Not true! I hear some chiropractors shout, we do not often treat children. Who is correct? Clearly, we need data to answer this question.
The objective of a new paper was to investigate characteristics of clinical chiropractic practice, including the age of pediatric patients, the number of reports of negative side effects (NSEs), the opinions of doctors of chiropractic on treatment options by patient age groups, the conditions seen and the number of treatment sessions delivered by conditions and by patient age.
An Internet cross-sectional survey was conducted in 20 European countries with 4109 chiropractors invited to reply. The 19 national associations belonging to the European Chiropractic Union and the Danish Chiropractic Association were asked to participate. Respondents were asked to self-report characteristics of their practices.
Of the 956 (23.3%) participating chiropractors, 921 reported 19821 pediatric patients per month. Children represented 8.1% of chiropractors’ total patient load over the last year. A total of 557 (534 mild, 23 moderate, and 0 severe) negative (adverse) side effects were reported for an estimated incidence of 0.23%. On the given treatment statements, chiropractors reported varying agreement and disagreement rates based on patient age. The 8309 answers on conditions were grouped into skeletal (57.0%), neurologic (23.7%), gastrointestinal (12.4%), infection (3.5%), genitourinary (1.5%), immune (1.4%), and miscellaneous conditions (0.5%). The number of treatment sessions delivered varied according to the condition and the patient age.
The authors of this survey concluded that this study showed that European chiropractors are active in the care of pediatric patients. Reported conditions were mainly skeletal and neurologic complaints. In this survey, no severe NSEs were reported, and mild NSEs were infrequent.
In my view, a more appropriate conclusion might be that MANY EUROPEAN CHIROPRACTORS ARE ACTIVE IN QUACKERY.
Osteopathy is a difficult subject. In the US, osteopaths are (almost) identical with doctors who have studied conventional medicine and hardly practice any manipulative techniques at all. Elsewhere, osteopaths are alternative healthcare providers specialising in what they like to call ‘osteopathic manipulative therapy’ (OMT). As though this is not confusing enough, osteopaths are doing similar things as chiropractors but are adamant that they are a distinct profession. Despite these assertions, I have seen little to clearly differentiate the two – with one exception perhaps: osteopaths tend to use techniques that are less frequently associated with severe harm.
Despite this confusion, or maybe because of it, we need to ask: DOES OMT WORK?
A recent study was aimed at assessing the effectiveness of OMT on chronic migraineurs using HIT-6 questionnaire, drug consumption, days of migraine, pain intensity and functional disability. All patients admitted to the Department of Neurology of Ancona’s United Hospitals, Italy, with a diagnosis of migraine and without chronic illness, were considered eligible for this 3-armed RCT.
Patients were randomly divided into three (1) OMT+medication therapy, (2) sham+medication therapy and (3) medication therapy only and received 8 treatments during 6 months. Changes in the HIT-6 score were considered as the main outcome measure.
A total of 105 subjects were included. At the end of the study, OMT significantly reduced HIT-6 score, drug consumption, days of migraine, pain intensity and functional disability.
The investigators concluded that these findings suggest that OMT may be considered a valid procedure for the management of migraineurs.
Similar results have been reported elsewhere:
One trial, for instance, concluded: “This study affirms the effects of OMT on migraine headache in regard to decreased pain intensity and the reduction of number of days with migraine as well as working disability, and partly on improvement of HRQoL. Future studies with a larger sample size should reproduce the results with a control group receiving placebo treatment in a long-term follow-up.”
Convinced? No, I am not.
Why? Because the studies that do exist seem a little too good to be true; because they are few and far between, because the few studies tend to be flimsy and have been published in dodgy journals, because they lack independent replications, and because critical reviews seem to conclude that OMT is nowhere near as promising as some osteopaths would like us to believe: “Further studies of improved quality are necessary to more firmly establish the place of physical modalities in the treatment of primary headache disorders. With the exception of high velocity chiropractic manipulation of the neck, the treatments are unlikely to be physically dangerous, although the financial costs and lost treatment opportunity by prescribing potentially ineffective treatment may not be insignificant. In the absence of clear evidence regarding their role in treatment, physicians and patients are advised to make cautious and individualized judgments about the utility of physical treatments for headache management; in most cases, the use of these modalities should complement rather than supplant better-validated forms of therapy.”
Necessity, they say, is the mother of invention. The meaning of this proverb is fairly clear:
- In the Oxford Dictionary the proverb has been defined as– when the need for something becomes imperative, you are forced to find ways of getting or achieving it.
- According to the Cambridge Dictionary, this is “an expression that means that if you really need to do something, you will think of a way of doing it.”
- Finally, the Longman dictionary has defined the proverb as– “if someone really needs to do something, they will find a way of doing it.”
In the world of chiropractic the proverb acquires a special meaning: chiropractic relies almost entirely on inventions. A few examples have to suffice:
- first, instead of pathophysiology, they invented subluxations,
- this required the invention of adjustments which were needed for their imagined subluxation,
- then they invented the ‘inate’,
- then they invented the idea that all sorts of conditions are caused by subluxations and therefore require adjustments,
- finally, they invented the notion that regular adjustments are needed for a healthy person to stay healthy.
I was reminded of the unique inventive capacity of chiropractic when I came across the website of the Foundation for Chiropractic Progress (F4CP). The F4CP is, according to their own statements, a not-for-profit organization dedicated to raising awareness about the value of chiropractic care (which is, of course, another invention).
Experts at the F4CP point out that a growing number of professional athletic teams utilize chiropractic care to maximize overall health and maintain peak performance. “Repetitive motion injuries, including shoulder tendinitis, elbow, lower back pain and muscle spasms, are common conditions and injuries among professional baseball players that can be successfully prevented, managed and treated with chiropractic care,” says Hirad N. Bagy, DC. “Chiropractic adjustments, in conjunction with soft tissue mobilization, provide athletes with proper structure, function and balance to reduce the risk of injury, accelerate recovery time and improve overall performance,” he continues – and he must know, because he has received specialized training and certifications specific to sports medicine, which include the Graston Technique®, Active Release Technique®, Myofascial Release Technique, Impact Concussion Testing and Functional Dry Needling. Dr. Bagy continues: “A number of athletes that I treat regularly understand the importance of chiropractic maintenance care, and also seek treatment when an injury arises. Through the restoration of proper bio-mechanics, doctors of chiropractic are now positioned as key health care providers throughout all of the sports teams that I work with.”
BRAVO! We are impressed! So much so, that we almost forgot to ask: “Is there any evidence for all of these therapeutic claims?”
Just as well! Because had we asked and perhaps even did a bit of research, we would have found that almost none of these far-reaching claims are evidence-based.
But who would be so petty? Instead of criticising the incessant flow of bogus claims made by chiropractors worldwide, we should really admire their remarkable skill of invention:
- When the need for profit becomes imperative, CHIROPRACTORS are forced to find ways of getting or achieving it.
- If CHIROPRACTORS really need to do something, they will think of a way of doing it.
- If a CHIROPRACTOR really needs money, he will advocate ‘maintenance care’.
AND THAT’S WHAT IS CALLED ‘CHIROPRACTIC PROGRESS’!
If you ask a chiropractor, you will probably be told that chiropractic spinal manipulation is a safe treatment. Unfortunately this is not quite true, as regular readers of this blog will appreciate. About half of all patients suffer mild to moderate adverse effects after chiropractic treatments and, in addition, many instances of much more serious complications have been documented, including rare cases of Horner syndrome. It results from an interruption of the sympathetic nerve supply to the eye and is characterized by the classic triad of miosis (ie, constricted pupil), partial ptosis, and loss of hemifacial sweating (ie, anhidrosis).
Danish neurologists recently reported the case of a 60-year-old man with no relevant medical history who was admitted to the Department of Neurology with drooping of his right upper eyelid and an ipsilateral contracted pupil, combined with pain, weakness, and numbness in his upper right limb.
The patient had experienced thoracic back pain of moderate intensity with radiating right-sided belt-like chest pain for 7 days. When the discomfort suddenly intensified, he sought chiropractic treatment. Following manipulations of the thoracic and cervical spine, the pain intensity initially lessened. Approximately one hour after chiropractic treatment, the patient experienced the eye and upper limb symptoms described above, for which he sought medical assistance three days later.
A detailed neurologic examination revealed moderate right-sided ptosis and miosis, no facial anhidrosis, decreased strength of the intrinsic and opponens muscles of the right hand, and reduced cutaneous sensation corresponding to the T1 dermatome, with inability to discriminate pain and light touch. The remaining clinical examination, routine blood tests, and vital parameters were unremarkable.
Brain CT scan and CT angiography including the aortic arch and neck vessels were performed and ruled out cerebral stroke and carotid artery dissection, respectively. As clinical signs of Horner syndrome and a concomitant radiating pain to the medial arm were considered suggestive of either a lower brachial plexopathy, i.e., due to a Pancoast tumor, or a radiculopathy, chest X-ray and electroneurography (ENG) were performed. No apical pulmonary pathology was detected. ENG of the right medial cutaneous antebrachial nerve demonstrated a normal sensory action potential (SAP), consistent with the lesion being located proximally to the dorsal spinal root ganglion, thus suggestive of a spinal nerve root lesion. A subsequent MRI of the thoracic spine showed a para-median herniation of the T1-T2 intervertebral disc compressing the right T1 spinal nerve root.
The patient received no surgery, and follow-up examination 6 months later revealed near-complete recovery, with only mild paraesthesia in the T1 segment of his right arm and a subtle ptosis remaining.
Horner syndrome due to a herniated thoracic disc has only been reported 6 times in the English language literature, though never preceded by chiropractic manipulation.
One of the most frequent causes of Horner syndrome is carotid artery dissection, which may occur spontaneously or due to local trauma to the neck region. Chiropractic manipulation as an independent risk factor for neck artery dissection and a consequent stroke is a controversial topic, though multiple cases of Horner syndrome due to ICA dissections subsequent to chiropractic manipulation have been reported. In the patient described here, an ICA dissection was considered unlikely due to the concomitant prominent radiating medial brachialgia and was furthermore ruled out by a CT angiogram of the neck vessels.
This patient experienced the onset of a Horner syndrome and ipsilateral upper limb symptoms shortly after chiropractic treatment, suggesting the cervico-thoracic manipulation as the cause of or at least worsening factor in the T1-T2 disc herniation. Several cases of disc herniations following chiropractic treatment have been reported.
While the definite pathophysiologic mechanism to explain this patient’s Horner syndrome remains unclear, it seems, according to the authors of this case-report, evident that manipulations as a minimum altered the configuration of an already existing disc protrusion.
Chiropractors like to promote themselves as primary healthcare professionals. But are they? A recent survey might go some way towards addressing this question. It was based on a cross sectional online questionnaire distributed to 4 UK chiropractic associations. The responses were collected over a period of two months from March 26th 2012 to May 25th 2012.
Of the 2,448 members in the 4 participating associations, 509 chiropractors (~21%) completed the survey. The results of the survey show that the great majority of UK chiropractors surveyed reported evaluating and monitoring patients in regards to posture (97.1%), inactivity/overactivity (90.8%) and movement patterns (88.6%). Slightly fewer provided this type of care for psychosocial stress (82.3%), nutrition (74.1%) and disturbed sleep (72.9%). Still fewer did so for smoking (60.7%) and over-consumption of alcohol (56.4%). Verbal advice given by the chiropractor was reported as the most successful resource to encourage positive lifestyle changes as reported by 68.8% of respondents. Goal-setting was utilised by 70.7% to 80.4% of respondents concerning physical fitness issues. For all other lifestyle issues, goal-setting was used by approximately two-fifths (41.7%) or less. For smoking and over-consumption of alcohol, a mere one-fifth (20.0% and 20.6% respectively) of the responding chiropractors set goals.
The authors of this survey concluded that UK chiropractors are participating in promoting positive lifestyle changes in areas common to preventative healthcare and health promotion areas; however, more can be done, particularly in the areas of smoking and over-consumption of alcohol. In addition, goal-setting to support patient-provider relationships should be more widespread, potentially increasing the utility of such valuable advice and resources.
When I saw that a new UK-wide survey of chiropractic has become available, I had great expectations. Sadly, they were harshly disappointed. I had hoped that, after going to the considerable trouble of setting up a nationwide survey of this nature, we would have some answers to the most urgent questions that currently plague chiropractic and are amenable to study by survey. In my view, some of these questions include:
- How many chiropractors actually see themselves as primary care professionals?
- What conditions do chiropractors treat?
- Specifically how many of them believe they can treat non-spinal conditions effectively?
- How many chiropractors regularly treat children?
- For which conditions?
- How many patients get X-rayed by chiropractors?
- How many are in favour of vaccinations?
- How many are aware of adverse effects of spinal manipulation?
- How chiropractors obtain informed consent before starting treatment?
- What percentage of chiropractors use spinal manipulation?
- What other treatments are used how often?
- How often do chiropractors advise their patients about medications prescribed by real doctors?
- How often do they refer patients to other health care providers?
All of these questions are highly relevant and none of them has recently been studied. But, sadly, the new paper does not answer them. Why? As I see it, there are several possibilities:
- Chiropractors do not find these questions as relevant as I do.
- They do not want to know the answers.
- They do not like to research issues that might shine a bad light on them.
- They view research mostly as a promotional exercise.
- They did research (some of) these questions but do not dare to publish the results.
- They will publish the results in a separate paper.
It would be interesting to hear from the authors which possibility applies.
Henry Louis Mencken (1880-1956) was an outspoken American journalist, essayist and literary critic famous for his vitriolic attacks on what he considered to be the hypocrisy of much of American life. In 1924, he published an essay on chiropractic which, I think, is still poignant today. I take the liberty of reproducing here in a slightly abbreviated form.
This preposterous quackery [chiropractic] flourishes lushly in the back reaches of the Republic, and begins to conquer the less civilized folk of the big cities. As the old-time family doctor dies out in the country towns, with no competent successor willing to take over his dismal business, he is followed by some hearty blacksmith or ice-wagon driver, turned into a chiropractor in six months, often by correspondence… [Chiropractic] pathology is grounded upon the doctrine that all human ills are caused by pressure of misplaced vertebrae upon the nerves which come out of the spinal cord — in other words, that every disease is the result of a pinch. This, plainly enough, is buncombe. The chiropractic therapeutics rest upon the doctrine that the way to get rid of such pinches is to climb upon a table and submit to a heroic pummeling by a retired piano-mover. This, obviously, is buncombe doubly damned.
…Any lout with strong hands and arms is perfectly equipped to become a chiropractor. No education beyond the elements is necessary. The takings are often high, and so the profession has attracted thousands of recruits — retired baseball players, work-weary plumbers, truck-drivers, longshoremen, bogus dentists, dubious preachers, cashiered school superintendents. Now and then a quack of some other school — say homeopathy — plunges into it. Hundreds of promising students come from the intellectual ranks of hospital orderlies.
…[The chiropractor’s] trade is mainly with ambulant patients; they must come to his studio for treatment. Most of them have lingering diseases; they tour all the neighborhood doctors before they reach him. His treatment, being nonsensical, is in accord with the divine plan. It is seldom, perhaps, that he actually kills a patient, but at all events he keeps any a worthy soul from getting well.
…But chiropractic, of course, is not perfect. It has superb potentialities, but only too often they are not converted into concrete cadavers. The hygienists rescue many of its foreordained customers, and, turning them over to agents of the Medical Trust, maintained at the public expense, get them cured. Moreover, chiropractic itself is not certainly fatal: even an Iowan with diabetes may survive its embraces. Yet worse, I have a suspicion that it sometimes actually cures. For all I know (or any orthodox pathologist seems to know) it may be true that certain malaises are caused by the pressure of vagrant vertebra upon the spinal nerves. And it may be true that a hearty ex-boilermaker, by a vigorous yanking and kneading, may be able to relieve that pressure. What is needed is a scientific inquiry into the matter, under rigid test conditions, by a committee of men learned in the architecture and plumbing of the body, and of a high and incorruptible sagacity. Let a thousand patients be selected, let a gang of selected chiropractors examine their backbones and determine what is the matter with them, and then let these diagnoses be checked up by the exact methods of scientific medicine. Then let the same chiropractors essay to cure the patients whose maladies have been determined. My guess is that the chiropractors’ errors in diagnosis will run to at least 95% and that their failures in treatment will push 99%. But I am willing to be convinced.
Where is there is such a committee to be found? I undertake to nominate it at ten minutes’ notice. The land swarms with men competent in anatomy and pathology, and yet not engaged as doctors. There are thousands of hospitals, with endless clinical material. I offer to supply the committee with cigars and music during the test. I offer, further, to supply both the committee and the chiropractors with sound wet goods. I offer, finally, to give a bawdy banquet to the whole Medical Trust at the conclusion of the proceedings.
I imagine that most chiropractors would find this comment rather disturbing. However, I do like it for several reasons:
- it is refreshingly politically incorrect; today journalists seem to be obsessed with the notion of ‘balance’ thus often creating the impression that there are two valid sides to an issue where, in fact, there is only one;
- it gets right at the heart of several problems which have plagued chiropractic from its beginning;
- it even suggests a way to establishing the truth about the value of chiropractic which could easily been followed some 90 years ago;
- finally it predicts a result of such a test – and I would not be surprised, if it turned out to be not far from the truth.
Please let me know what you think, regardless of whether you are a chiropractor or not.
Neck pain is a common problem which often causes significant disability. Chiropractic manipulation has become one of the most popular forms of alternative treatment for such symptoms. This seems surprising considering that neck manipulations are neither convincingly effective nor free of adverse effects.
The current Cochrane review on this subject could not be clearer: “Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior.” In the absence of compelling evidence for efficacy, any risk of neck manipulation would tilt the risk/benefit balance into the negative.
Adverse effects of neck manipulations range from mild symptoms, such as local neck tenderness or stiffness, to more severe injuries involving the spinal cord, peripheral nerve roots, and arteries within the neck. A recent paper reminds us that another serious complication has to be added to this already long list: phrenic nerve injury.
The phrenic nerve is responsible for controlling the contractions of the diaphragm, which allows the lungs to take in and release air and make us breathe properly. The phrenic nerve is formed from C3, C4, and C5 nerve fibres and descends along the anterior surface of the scalenus anterior muscle before entering the thorax to supply motor and sensory input to the diaphragm. Its anatomic location in the neck leaves it vulnerable to traumatic injury. Phrenic nerve injury can result in paralysis of the diaphragm and often leads to deteriorating function of the diaphragm, which can lead to partial or complete paralysis of the muscle and, as a result, serious breathing problems.
Patients who experience such problems may require emergency medical treatment or surgery. Sudden, severe damage to the phrenic nerve can make it impossible for the diaphragm to contract on its own. In order to make sure that the patient can breathe, a breathing tube needs to be inserted, a process called intubation. Artificial respiration would then be required.
American neurologists published a case report of a healthy man who consulted a chiropractor for his neck pain. Predictably, the chiropractor employed cervical manipulation to treat this condition. The result was bilateral diaphragmatic paralysis.
Similar cases have been reported previously, for instance, here and here and here and here. Damage to other nerves has also been documented to be a possible complication of spinal manipulation, for instance, here and here.
The authors of this new case report conclude that physicians must be aware of this complication and should be cautious when recommending spinal manipulation for the treatment of neck pain, especially in the presence of preexisting degenerative disease of the cervical spine.
I know what my chiropractic friends will respond to this post:
- I am alarmist,
- I cherry-pick articles that are negative for their profession,
- these cases are extreme rarities,
- conventional medicine is much more dangerous.
To this I reply: Imagine a conventional therapy about which the current Cochrane review says that it has no proven effect for the condition in question. Imagine further that this therapy causes mild to moderate adverse effects in about 50% of all patients in addition to very dramatic complications which are probably rare but, as no monitoring system exists, of unknown frequency. Imagine now that the professionals using this treatment more regularly than any other clinicians steadfastly deny that the risk/benefit balance is way out of kilter.
Would you call someone who repeatedly tries to warn the public of this situation ‘alarmist’?
Would you not consider the professionals who continue to practice the therapy in question to be irresponsible?
A recent article from THE CHIROPRACTIC REPORT entitled ‘Media Criticism – Whether and How to Respond’ has caught my attention. It provides detailed and, in my view, quite remarkable advice to chiropractors as to how they should react to criticism. Here is an excerpt:
…the easiest media comment to challenge is one that makes an absolute claim – for example Salzberg’s claim that the practice of chiropractic is “highly dubious.” It also means that an effective response should usually not be absolute – claiming for example that chiropractic care can cure, or a specific chiropractic treatment is proven effective for, a specific condition.
Let’s explore this with an example. In 2008 a British journalist, Simon Singh, while promoting a new book he had co-authored that was heavily critical of chiropractic and complementary and alternative medicine in general, wrote an article in the Guardian newspaper in which he claimed that “there is not a jot of evidence” that chiropractic treatment can help children with “colic, sleeping and feeding problems . . . and prolonged crying.” In other words, a black and white claim.
There was and is evidence. Singh was wrong. How might you respond to this? Here are your options for reply, from the outspoken to the restrained:
a. Chiropractic is proven effective for the cure of infantile colic.
b. Spinal manipulation is proven effective for the cure of infantile colic
c. Manual treatments are proven effective for the cure of infantile colic
d. Chiropractic/spinal manipulation/ manual therapies may be effective in reducing the symptoms of infantile colic.
e. Where spinal joint dysfunction/subluxation is found, chiropractic/spinal manipulation/manual therapies may be effective in reducing abnormal and incessant crying in infants medically diagnosed as having infantile colic
f. Chiropractic care has a central focus of assessing and correcting spinal joint dysfunction/subluxation and its biomechanical and physiological effects, and where these are addressed many symptoms may be reduced including those associated with infantile colic.
The first three options are as black and white as Singh’s statement, and are not supported by the evidence. Some studies say yes, some no. All the other options, which have appropriate qualifiers and shades of gray, are supported by sound evidence.
Much of that evidence is referred to and referenced in the March 2010 issue of this Report, available online at www.chiropracticreport.com/pastissues. To answer Singh effectively one only has to produce some of the good quality research and question how he can be credible when he says “there is not a jot of evidence”.
With respect to evidence, in this context that means evidence published in peer-reviewed scientific journals. You may decide to comment on one or more anecdotal case reports from your practice to give your response greater human interest, but this will mean nothing unless supported by higher levels of published evidence.
Am I the only one to find this remarkable?
Am I wrong in interpreting this as detailed instructions to mislead the public?
Are these instructions not merely advice to defend chiropractic commercial interests at the expense of public health?
How can this be ethical?
Few subjects lead to such heated debate as the risk of stroke after chiropractic manipulations (if you think this is an exaggeration, look at the comment sections of previous posts on this subject). Almost invariably, one comes to the conclusion that more evidence would be helpful for arriving at firmer conclusions. Before this background, this new publication by researchers (mostly chiropractors) from the US ‘Dartmouth Institute for Health Policy & Clinical Practice’ is noteworthy.
The purpose of this study was to quantify the risk of stroke after chiropractic spinal manipulation, as compared to evaluation by a primary care physician, for Medicare beneficiaries aged 66 to 99 years with neck pain.
The researchers conducted a retrospective cohort analysis of a 100% sample of annualized Medicare claims data on 1 157 475 beneficiaries aged 66 to 99 years with an office visit to either a chiropractor or to a primary care physician for neck pain. They compared hazard of vertebrobasilar stroke and any stroke at 7 and 30 days after office visit using a Cox proportional hazards model. We used direct adjusted survival curves to estimate cumulative probability of stroke up to 30 days for the 2 cohorts.
The findings indicate that the proportion of subjects with a stroke of any type in the chiropractic cohort was 1.2 per 1000 at 7 days and 5.1 per 1000 at 30 days. In the primary care cohort, the proportion of subjects with a stroke of any type was 1.4 per 1000 at 7 days and 2.8 per 1000 at 30 days. In the chiropractic cohort, the adjusted risk of stroke was significantly lower at 7 days as compared to the primary care cohort (hazard ratio, 0.39; 95% confidence interval, 0.33-0.45), but at 30 days, a slight elevation in risk was observed for the chiropractic cohort (hazard ratio, 1.10; 95% confidence interval, 1.01-1.19).
The authors conclude that, among Medicare B beneficiaries aged 66 to 99 years with neck pain, incidence of vertebrobasilar stroke was extremely low. Small differences in risk between patients who saw a chiropractor and those who saw a primary care physician are probably not clinically significant.
I do, of course, applaud any new evidence on this rather ‘hot’ topic – but is it just me, or are the above conclusions a bit odd? Five strokes per 1000 patients is definitely not “extremely low” in my book; and furthermore I do wonder whether all experts would agree that a doubling of risk at 30 days in the chiropractic cohort is “probably not clinically significant” – particularly, if we consider that chiropractic spinal manipulation has so very little proven benefit.
My message to (chiropractic) researchers is simple: PLEASE REMEMBER THAT SCIENCE IS NOT A TOOL FOR CONFIRMING BUT FOR TESTING HYPOTHESES.
On 1/12/2014 I published a post in which I offered to give lectures to students of alternative medicine:
Getting good and experienced lecturers for courses is not easy. Having someone who has done more research than most working in the field and who is internationally known, might therefore be a thrill for students and an image-boosting experience of colleges. In the true Christmas spirit, I am today making the offer of being of assistance to the many struggling educational institutions of alternative medicine .
A few days ago, I tweeted about my willingness to give free lectures to homeopathic colleges (so far without response). Having thought about it a bit, I would now like to extend this offer. I would be happy to give a free lecture to the students of any educational institution of alternative medicine.
I did not think that this would create much interest – and I was right: only the ANGLO-EUROPEAN COLLEGE OF CHIROPRACTIC has so far hoisted me on my own petard and, after some discussion (see comment section of the original post) hosted me for a lecture. Several people seem keen on knowing how this went; so here is a brief report.
I was received, on 14/1/2015, with the utmost kindness by my host David Newell. We has a coffee and a chat and then it was time to start the lecture. The hall was packed with ~150 students and the same number was listening in a second lecture hall to which my talk was being transmitted.
We had agreed on the title CHIROPRACTIC: FALLACIES AND FACTS. So, after telling the audience about my professional background, I elaborated on 7 fallacies:
- Appeal to tradition
- Appeal to authority
- Appeal to popularity
- Subluxation exists
- Spinal manipulation is effective
- Spinal manipulation is safe
- Ad hominem attack
Numbers 3, 5 and 6 were dealt with in more detail than the rest. The organisers had asked me to finish by elaborating on what I perceive as the future challenges of chiropractic; so I did:
- Stop happily promoting bogus treatments
- Denounce obsolete concepts like ‘subluxation’
- Clarify differences between chiros, osteos and physios
- Start a culture of critical thinking
- Take action against charlatans in your ranks
- Stop attacking everyone who voices criticism
I ended by pointing out that the biggest challenge, in my view, was to “demonstrate with rigorous science which chiropractic treatments demonstrably generate more good than harm for which condition”.
We had agreed that my lecture would be followed by half an hour of discussion; this period turned out to be lively and had to be extended to a full hour. Most questions initially came from the tutors rather than the students, and most were polite – I had expected much more aggression.
In his email thanking me for coming to Bournemouth, David Newell wrote about the event: The general feedback from staff and students was one of relief that you possessed only one head, :-). I hope you may have felt the same about us. You came over as someone who had strong views, a fair amount of which we disagreed with, but that presented them in a calm, informative and courteous manner as we did in listening and discussing issues after your talk. I think everyone enjoyed the questions and debate and felt that some of the points you made were indeed fair critique of what the profession may need to do, to secure a more inclusive role in the health care arena.
My own impression of the day is that some of my messages were not really understood, that some of the questions, including some from the tutors, seemed like coming from a different planet, and that people were more out to teach me than to learn from my talk. One overall impression that I took home from that day is that, even in this college which prides itself of being open to scientific evidence and unimpressed by chiropractic fundamentalism, students are strangely different from other health care professionals. The most tangible aspect of this is the openly hostile attitude against drug therapies voiced during the discussion by some students.
The question I always ask myself after having invested a lot of time in preparing and delivering a lecture is: WAS IT WORTH IT? In the case of this lecture, I think the answer is YES. With 300 students present, I am fairly confident that I did manage to stimulate a tiny bit of critical thinking in a tiny percentage of them. The chiropractic profession needs this badly!
