[bpsdb] Guest blogger "Blue Wode" has produced a definitive review of the science and evidence (or lack of) behind claims made by the BCA, GCC and other chiropractic advocates. [Written by Blue Wode, edited by Martin Robbins]
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It has become apparent that the Achilles’ heel of chiropractic - promoted as an effective, cost-effective, and safe alternative to drugs and surgery for a range of health conditions - is negative publicity. One wonders whether this insecurity is behind the chiropractic industry’s frequent failure to cite the more robust, but unfavourable, scientific research on its interventions.
For example, not only do the British Chiropractic Association (BCA), and the College of Chiropractors (currently seeking a Royal Charter) omit some of the better scientific evidence from their websites; even the UK statutory regulatory body, the General Chiropractic Council (GCC) (created to protect patients and set standards of chiropractic education, conduct and practise) does. It presently claims that:
"The main treatments of chiropractic have been shown consistently in reviews to be more effective than the treatments to which they have been compared."
...and that chiropractic intervention, including manipulation, is:
"Safe, effective and cost-effective in reducing referral to secondary care."
However, that appears to be a misrepresentation of the facts. As Professor David Colquhoun wrote in a letter to The Times last August, recent research has shown chiropractic to be less safe and no more effective than conventional treatments that are much cheaper [1,2].
It is important at this point to understand that spinal manipulative therapy is not chiropractic, but rather a technique that chiropractors have adopted. Real chiropractic involves the detection of imaginary ‘subluxations’ which chiropractors supposedly correct by administering ‘specific spinal adjustments’ which they allege will enhance a person’s health. Often chiropractors seem to confuse the two approaches, perhaps to give their practices an air of legitimacy, but many others will admit outright that traditional chiropractic beliefs are central to their interventions.
The GCC, and others, continue to stand by their claims for the evidence for chiropractic despite controversy surrounding the studies they promote, such as the 2004 UK BEAM Trial, and the 1990 Meade report and its follow-up [3,4,5]. The GCC also promotes the European guidelines for the management of low back pain which, although the GCC implies that they recommend chiropractic, only briefly mention spinal manipulation. On top of that, the Royal College of General Practitioners withdrew chiropractic spinal manipulation from its guidelines in 2005, although some chiropractic websites continue to mention them.
Perhaps most disturbing of all, is that the GCC is adamant that chiropractic neck manipulation is safe. Oddly, it claims this even though, by virtue of its statutory empowerment, it doesn’t seem to have a duty to care for patients by regulating the safety of chiropractic treatments (nor, for that matter, does it seem to have a legal obligation to define the scope of practice for its registrants).
So just how safe is chiropractic neck manipulation? A responsible risk/benefit assessment suggests, very strongly, that it is an unacceptable technique when there are equally effective, but safer, options available such as exercise or massage. Other assessments have reached similar conclusions [6]. Indeed, Fig. 2 in this paper (reproduced below) serves to demonstrate why it would probably be wise to avoid neck manipulation by chiropractors [7].
Practitioners providing manipulation of the cervical spine that resulted in injury (IE users click here if it doesn't display).
Interestingly, these criticisms also suggest that chiropractors may not be able to provide a risk/benefit ratio for manipulative treatment of the cervical spine. As a consequence, patients would not be able to be fully informed of the risks and benefits of their proposed treatment despite chiropractors being required to do so by section B2.7 of their Code of Practice.
In spite of the above concerns, last year, following the publication of a dubious multi-centre research study in Canada, the GCC decided to declare publicly that the there was no evidence that manipulation of the neck (by any health professional) caused stroke, and went on to say that it could extrapolate from that study that:
"Some people suffering the symptoms of the onset of a stroke consult primary healthcare practitioners – not that the health practitioners cause the stroke."
Those claims are disturbing for a number of reasons:
1. They appear to negate chiropractors’ legal burden of disclosure of risk (at least for neck manipulation).
2. Chiropractors should know from their training that neck manipulation is contraindicated if a patient has, or is suspected to have, a stroke in progress.
3. The impact of the GCC’s views could easily see UK chiropractors becoming even more disinclined to use the Chiropractic Reporting and Learning System' (CRLS) which the BCA attempted to implement nationally in 2005, and which, since then, according to a study published in July 2008 [8], has been very much under-utilised. This finding in itself indicates that the GCC’s recommendations on patient safety, which were made clear in Item 7 of the minutes of its 2nd March 2006 meeting, are not being fully met.
4. The GCC’s views on the study will undoubtedly be seen by many chiropractors as confirming the results of a prospective national survey into the safety of chiropractic manipulation of the cervical spine which were published in Spine in October 2007, and which found that the risk of a serious adverse event, immediately or up to 7 days after treatment, was low to very low.
Regarding point 4, last year Professor Edzard Ernst questioned the integrity of the methodology used in that survey, and highlighted the very real problem of
"Having to rely on the honesty of participating therapists [chiropractors] who could have a very strong interest in generating a reassuring yet unreliable picture about the safety of their intervention."
Interestingly, in their response, two of the survey’s authors, JE Bolton and HW Thiel, claimed that, in the UK alone, there were an estimated four million manipulations of the neck carried out by chiropractors each year. Yet, six months earlier, in October 2007, in a letter to the Journal of the Royal Society of Medicine, they claimed that the figure was "estimated to be well over two million cervical spine manipulations". How that estimate could double in under 6 months is anyone’s guess, but it leaves them open to accusations that they may be trying to play down the risks. It’s also worth noting that in 2002, co-author, JE Bolton, seemed to have no qualms about recommending chiropractic as a placebo treatment for infants with colic in the apparent absence of published safety data [9,10].
(That latter study does not consider the harmful aspects of chiropractic care that are far more common than the reported events. They include decreased use of immunisation due to misinformation given to parents, financial harm due to unnecessary treatment, and psychological harm related to unnecessary treatment and exposure to false chiropractic beliefs about "subluxations”. See: http://www.ncahf.org/digest07/07-14.html .)
Returning to the dubious Canadian study, the GCC’s claims that it signifies that there is no evidence that manipulation of the neck (by any health professional) causes stroke and that...
"...some people suffering the symptoms of the onset of a stroke consult primary healthcare practitioners – not that the health practitioners cause the stroke..."
...do not seem to be supported by the data. Rather, the study reveals an intriguing "smoking gun" which is discussed here. In addition to that, it’s worth noting that the study’s lead author, David Cassidy, DC, came under some fierce (but apparently deserved) criticism from Sharon Mathiason, a mother whose daughter died following chiropractic neck manipulation for a tailbone injury. Unfortunately, however, the study formed part of a report by the Task Force on Neck Pain and its Associated Disorders that the American Chiropractic Association decided to send out to over 16,000 neurologists.
It’s disappointing that most chiropractors tend to condemn the evidence for neck manipulation causing stroke as anecdotal when, in many cases, it is exactly that sort of evidence which they rely on to promote their services. It’s a point that’s addressed in paragraph 146 of the Statement of Claim of tetraplegic chiropractic victim, Sandra Nette. In essence, it asserts that many chiropractors, as well as their regulators and professional associations, seem to find it acceptable to promote anecdotal or weak evidence where it supports chiropractic treatment, but where similar, or more robust, evidence suggests that serious complications (e.g. stroke) can result from it, they are known to be quick to dismiss it. Coincidentally, that Statement of Claim also contains two paragraphs, 85 and 193, which appear to very closely describe the way in which chiropractic is regulated in the UK.
A good example of questionable chiropractic regulatory behaviour can be found in this July 2004 letter which the GCC sent to Alastair McLellan, editor of the Health Service Journal. In the letter, the GCC scolded Mr McLellan for publishing an article by Professor Edzard Ernst entitled ‘Beyond The Fringe’. The GCC denounced it as being "nothing more than an ill-founded attack on UK chiropractors", before going on to claim that Professor Edzard Ernst "…refuses to engage in any meaningful dialogue with the UK chiropractic profession."
Well, just over a year later, Professor Ernst attended one of the GCC’s meetings, and the following is what the GCC chose to write about his visit in its open minutes of that meeting:
A copy of Professor Ernst’s presentation is attached as Appendix A to these Minutes. Questions to Professor Ernst in the subsequent debate included:
• Are you familiar with the work of Herzog et al regarding the physical characteristics of cervical spine manipulation and its effect on the vertebral artery?
• How do you rationalise your view of the chiropractic profession as responsible for most serious adverse affects when osteopaths, some physiotherapists and other professionals also engage on a global basis in manipulation of the cervical spine?
• Why do you say that osteopaths use mobilisation, which is inherently safer and chiropractors only manipulate, which carries more risk?
• Where is your evidence of "serious adverse events, such as stroke (sometimes fatal) are regularly reported"?
However, Appendix A, and the minutes of the ensuing debate, seem to be for chiropractors’ eyes only. In the interests of preventing any stifling of discussion regarding their content, a Freedom of Information request is perhaps in order. (Anyone making such a request should stand a good chance of having it granted since the GCC prides itself on being a transparent and helpful regulatory body.)
In defence of the risks associated with their practices, chiropractors often cite the many problems encountered by the medical profession. For example, drugs have side effects, even when used properly, and surgery is not without risks. However, physicians often work with drugs and surgery in an effort to prolong and/or save lives, and many of their patients will have been destined to die irrespective of having undergone medical interventions. Chiropractors, on the other hand, invariably deal with non-life threatening, chronic diseases, and do not, as a rule, save lives or use invasive techniques which would carry the risk of haemorrhage and infection.
Chiropractors also often claim in their defence that only 10-15% of current medical interventions are supported by evidence although the real figure is nearer 80%. On the subject of quality of evidence [11], the GCC stipulates in section A2.3 of its Standard of Proficiency that chiropractors’ provision of care must be evidence based. However, it’s disquieting that its glossary page defines evidence-based care as:
"...clinical practice that incorporates the best available evidence from research, the preferences of the patient and the expertise of practitioners (including the individual chiropractor her/himself)."
...and the word ‘must’ as:
"...signifies that the practitioner has to comply. In order to comply chiropractors will need to exercise their judgment."
One could be forgiven for thinking that rather than demanding that chiropractors uphold proper standards of evidence-based practice, those definitions give them carte blanche to do whatever they like.
With regard to public trust, the GCC requires that all chiropractors must ensure that all the information they provide, or authorise others to provide on their behalf, is:
• factual and verifiable
• is not to be misleading or inaccurate in any way
• does not, in any way, abuse the trust of members of the public nor exploit their lack of experience or knowledge about either health or chiropractic matters
• does not put pressure on people to use chiropractic, for example by arousing ill-founded fear for their future health or suggesting that chiropractic can cure serious disease
However, how the GCC can reconcile the above with its own definition of a chiropractic subluxation, and with its claim that chiropractic is safe, remains unclear.
What will soon become clear, though, is whether or not chiropractic has been recommended in NICE’s new guidelines for the treatment of low back pain. It’s worth bearing in mind the recent comments made by the blog, Ministry of Truth:
"If NICE approves the use of chiropractic manipulation as part of the treatment regime for lower back pain then the door opens to chiropractors taking referrals from the NHS under contracts in which the NHS pays their fees and before you can say ‘vested interest’ you’ve got a whole bunch of chiropractors on what is effectively the public payroll. Little wonder then that just about the last thing that the BCA want right now is science journalists asking all sorts of awkward questions like ‘is there any evidence to show that it works?’ and ‘what kind of risks might patients face when referred for a course of woo?’."
...because if NICE does recommend chiropractic spinal manipulation for low back pain, then questions will surely be asked about the sources of evidence it used to formulate such a recommendation. Its reply will be particularly interesting, not least because, after thoroughly evaluating the evidence on chiropractic in their recent book Trick or Treatment? Alternative Medicine on Trial, British scientists, Simon Singh and Edzard Ernst, propose (p.285) that all chiropractors be compelled by law to disclose the following to their patients prior to treatment:
"WARNING: This treatment carries the risk of stroke or death if spinal manipulation is applied to the neck. Elsewhere on the spine, chiropractic therapy is relatively safe. It has shown some evidence of benefit in the treatment of back pain, but conventional treatments are usually equally effective and much cheaper. In the treatment of all other conditions, chiropractic therapy is ineffective except that it might act as a placebo."
Notwithstanding a pathological curiosity about the word bogus, the above begs the following obvious question - why would any informed person risk their money and their life going to see a chiropractor?
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Follow us on Twitter! @mjrobbins | @blue_wode
More on Simon Singh vs. the BCA
For a comprehensive list of blog posts on Singh vs. BCA see:
http://godknowswhat.wordpress.com/2009/05/16/simon-singh-case-response-r...
Further reading/viewing:
2008 Kinsinger Report on Chiropractic (42 min. video)
UK Skeptics resource on chiropractic:
http://www.skeptics.org.uk/article.php?dir=articles&article=chiropractic...
What’s the harm in going to a chiropractor?
http://whatstheharm.net/chiropractic.html
Action for Victims of Chiropractic
http://www.chirovictims.org.uk/index.html
Chiropractic Stoke Awareness Group
http://www.chiropracticstroke.com/about.php
Victims of Chiropractic Abuse
http://www.vocact.com/
Victims of Chiropractic Abuse (3 min. video)
Victims Of Irresponsible Chiropractic Education and Standards
http://www.voicesusa.org/pages.php?section=1&catid=1&id=24
Neck 911 USA
http://www.neck911usa.com
Chiropractors and x-rays
http://www.quackometer.net/blog/2009/01/is-chiropractic-x-raying-illegal...
Chiropractic educational standards in the UK
http://www.quackometer.net/blog/2008/08/role-of-uk-universities-in-chiro...
Chirobase
http://www.chirobase.org/
Peer-Reviewed References Cited:
[1] Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, & Shekelle PG (2004). Spinal manipulative therapy for low-back pain Cochrane Database of Systematic Reviews (1) DOI: 10.1002/14651858.CD000447.pub2
[2] Canter, P., Coon, J., & Ernst, E. (2006). Cost-Effectiveness of Complementary Therapies in the United Kingdom--A Systematic Review Evidence-based Complementary and Alternative Medicine, 3 (4), 425-432 DOI: 10.1093/ecam/nel044
[3] . (2004). United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care BMJ, 329 (7479) DOI: 10.1136/bmj.38282.669225.AE
[4] Assendelft WJ, Bouter LM, & Kessels AG. (1991). Effectiveness of chiropractic and physiotherapy in the treatment of low back pain: a critical discussion of the British Randomized Clinical Trial. J Manipulative Physiol Ther, 14 (5), 281-286
[5] Meade TW, Dyer S, Browne W, & Frank AO (1995). Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up BMJ, 5, 349-351
[6] Ernst, E. (2006). A systematic review of systematic reviews of spinal manipulation Journal of the Royal Society of Medicine, 99 (4), 192-196 DOI: 10.1258/jrsm.99.4.192
[7] Di Fabio RP (1999). Manipulation of the cervical spine: risks and benefits.
Phys Ther, 79, 50-65
[8] GUNN, S., THIEL, H., & BOLTON, J. (2008). British Chiropractic Association members’ attitudes towards the Chiropractic Reporting and Learning System: A qualitative study Clinical Chiropractic, 11 (2), 63-69 DOI: 10.1016/j.clch.2008.04.003
[9] Hughes, S. (2002). Is chiropractic an effective treatment in infantile colic? Archives of Disease in Childhood, 86 (5), 382-384 DOI: 10.1136/adc.86.5.382
[10] Vohra, S., Johnston, B., Cramer, K., & Humphreys, K. (2007). Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic Review PEDIATRICS, 119 (1) DOI: 10.1542/peds.2006-1392
[11] Wien Klin Wochenschr. 2005, Canter PH, & Ernst E (2005). Sources of bias in reviews of spinal manipulation for back pain. Wien Klin Wochenschr., 117, 333-341
http://layscience.net/trackback/566
Fantastic sumation, and well worth the time taken to compile it.
There surely cannot be many chiropractors who remain unaware that there is "not a jot" of evidence for their interventions.
Excellent! In the last sentence, shouldn't that be “raises” rather than “begs” though? :)
"Ongoing research into the chiropractic profession is vital as one of the key requirements to assist decision making within the National Health Service is the presence of evidence based research and cost effectiveness."
Source: 2007 Annual Report of the British Chiropractic Association (http://www.chiropractic-ecu.org/UserFiles/File/ECU%20Download%20page/Gre...)
A good laugh at the contents of this report can be found at: http://www.thinkhumanism.com/phpBB3/viewtopic.php?f=14&t=3097&p=54578#p5...
Excellent review - well written and referenced. Many thanks.
T
Great stuff.
excellent stuff
one small thing. the holy testament and manifesto of evidence based medicine (linked below) says that EBM is about applying the best available evidence to a clinical problem also taking into account things like patient preference, local service provision and clinician's experience, rather than the slavish following of data and protocols. this is a good thing. i suspect the chiropractors were implicitly quoting that in their similar blueprint for evidence based practise.
http://www.bmj.com/cgi/content/extract/312/7023/71
otherwise bravo!
b
Glad you liked it :)
In the bit Blue Wode quoted that I think you're referring to, I think he was drawing attention more to the vagueness of the guidelines, that allowed chiropractors to make calls based on "their own experience and judgement", but I accept your point, and you're probably right about the plagiarism... which is quite ironic really!
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Interseting assessment. You appear to suggest that evidence reviews on safety and efficacy conducted by the RCGP (note these guidelines were superceeded by the European Guidelines) the European Low back Pain Guidelines and NICE are incorrect and thus the guidelines inappropriate.
Are you also suggesting that the larege multidisciplinary panels of clinical experts involved in producing these guidelines have all being misled?
Furthermore you appear to imply that the truth lies only with the works of Ernst and Singh, neither of whom are registered clinicians, and may be considered to have a vested interest in selling books and newspapers.
@Anonymous:
I can't answer for Blue_Wode as it's not my article, but a few points:
The truth lies with the balance of the available evidence, not with Singh, Ernst, or any other individual. Singh's interests regarding chiropracty are, I suspect, rather less vested than chiropractors, particularly given that this current court case may cost him hundreds of thousands of pounds. Also, I have no idea what you mean when you talk about "evidence reviews" of chiropracty in the European Low Back Pain Guidelines - they barely mention chiropractic on their entire website. Ditto NICE. Regardless, again, what matters is the balance of evidence, not which panel says what.
And on that, well, you've not really said anything. Which parts of the evidence presented do you think are incorrect, and why?
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Thank you for your comments, anonymous.
Bearing in mind that Alan Breen (DC), Professor of Musculoskeletal Heath Care at the UK’s Anglo European College of Chiropractic, collaborated in the development of the European Acute Back Pain Guidelines, it’s worth noting Professor Edzard Ernst’s comments on official guidelines for the treatment of back pain:
Quote:
"Chiropractors argue that their approach must be safe and effective, not least because the official guidelines on the treatment of back pain recommend using chiropractic. However, this is true only for some, but by no means all, countries.
Secondly, guidelines are well known to be influenced by the people who serve on the panel that develops them. Cochrane reviews, on the other hand, are generally considered to be objective and rigorous. Writing about the importance of systematic reviews for health care in the Lancet, Sir Ian Chalmers stated, ‘I challenge decision makers within those spheres who continue to frustrate efforts to promote this form of research to come out from behind their closed doors and defend their attitudes and policies in public. There is now plenty of evidence to show how patients are suffering unnecessarily as a result of their persuasive influence.’"
The Value of Chiropractic
http://www.medicinescomplete.com/journals/fact/current/fact1002a02t01.htm
It’s also worth noting that Professor Ernst was the Head of the Department of Physical and Rehabilitation Medicine in the University of Vienna’s Medical Faculty. As a consequence, not only is he very familiar with physical therapies, he has also been trained in spinal manipulation and has applied it clinically. See the end of his Systematic review of case reports of serious adverse events following manipulation of the cervical spine (1995–2001) here:
http://www.mja.com.au/public/issues/176_08_150402/ern10520_fm.html
In view of the above, it is clear that, as an impartial scientist, he likes to apply a cautionary attitude in the interests of patient safety.
With regard to the soon-to-be-published NICE clinical guidelines on low back pain, it’s worth noting that a chiropractor, an osteopath, and an acupuncturist served on the Guideline Development Group:
http://www.nice.org.uk/nicemedia/pdf/LowBackPainGDGMembersList270407.pdf
The chiropractic representative was the Chairman of the GCC, Peter Dixon, who is described as having “experience and working knowledge of non specific low back pain”. An interesting example of his work in his capacity as Chairman of the GCC can be found here:
http://www.gcc-uk.org/files/link_file/DAILY%20MAIL%2012%20December%20200...
Peter Dixon is also, of course, a past president of the British Chiropractic Association, authors of the, er, much debated Happy Families leaflet.
Actually I would have expected any guideline development group working on low back pain to have included a chiropractor and an osteopath. As statutorily regulated health care professions that frequenly treat low back pain this seems entirely appropriate. I believe the group also included a GP, spinal surgeon, pain specialist, pharmacist, a nurse and a lay member. So I don't understand what point you are trying to make, unless you wish to take on the medical establishment, NICE etc
You once again seem to rely on the "opinions" of Ernst based largely on case reports and reviews often quoting his own work, that most serious objective scientists would judge selective at best. If he is truely an expert in the techniques as you say it would be interesting to see his formal qualifications in these disciplins and the details of the courses that he has completed.
@Anonymous Again, I can't speak for Blue Wode, but all you're doing is a) ignoring the evidence you don't like, and b) appealing to an authority who c) don't actually appear to support your position anyway.
You also seem obsessed with Ernst, which is odd considering that some 53 sources were cited in this article, including 11 pieces of peer-reviewed research of which only 3 included Ernst as a co-author. And even for these three, you've given no reason for anyone to disregard Ernst's findings, such as methodological failings, dodgy analysis etc.
You are not helping your case much. You need to start dealing with, and citing, evidence.
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Thank you for your further comments, anonymous.
Bearing in mind that around 60-70% of chiropractors who responded to a recent UK survey admitted that chiropractic philosophy (Innate/subluxation-based practice) was central to their interventions, how can patients entering chiropractic clinics be confident that they will be treated appropriately?
Also, it’s really quite worrisome that a man like Peter Dixon, who insists that there’s no available evidence to show that manipulation of the neck by chiropractors has ever caused a stroke, has been serving as a trusted member of a clinical excellence team. With reference to the comments in this link,
http://www.healthwatcher.net/chirowatch.com/cw-cervical.html
(scroll down to ‘Edzard Ernst again challenges chiropractors in UK’), it would be interesting to know if it was a solid background in research that qualified Mr Dixon to be part of NICE’s Guideline Development Group.
I agree that you would expect representatives of these professions (and I am using the word they prefer in an attempt to be non-judgemental) to be there on that "stakeholder" basis - but I find the choice of actual people interesting.
It is one thing to choose, say, a manipulative therapist with a clear commitment to evidence-based practice, and some history with the NHS. I am sure you could find such people, like blogger and osteopath Jonathan Hearsey. You might also go for someone with demonstrable experience in grading evidence in an academic setting.
It is another thing, arguably, to choose a kind of "shop steward" figure - like a past President of a chiropractic professional association - who you might say has a clear vested interest in defending any and all actions of his chosen profession. I am somehow searching for an analogy between putting Peter Dixon on the NICE Back Pain Guideline group to represent chiropractic, and having the outgoing House of Commons Speaker on a group investigating MPs expenses claims, and recommending new ways to police expenses. It is clearly possible, and may even be what happens. But... I wonder who thinks it is the best way to get at the truth?
This is an excellent piece of research and reporting.
pathetic everything you say...such a waste of time and lack of information...
Ha ha, thanks for your considered and detailed rebuttal.
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'It is one thing to choose, say, a manipulative therapist with a clear commitment to evidence-based practice, and some history with the NHS. I am sure you could find such people, like blogger and osteopath Jonathan Hearsey. You might also go for someone with demonstrable experience in grading evidence in an academic setting.'
Did someone call?
Great post, but only what I would expect from Blue Wode.
I'm bang up for some researching but am not from an academic background so if someone has got a simple way of testing what I do in the situation where I work then I'm all ears. Really. This BCA/Singh issue has got out of hand and something must be done about it.
Jonathan Hearsey
My friend, I started reading this CRAPPY ARTICLE, but after few lines, I wanted to throw up, so i stopped.
WHY DID U FORGET TO MENTION THAT:
Results of Assessment of Injuries Associated
With Cervical Manipulation
One hundred seventy-seven cases were reported in 116
articles.† The case reports were published between 1925
and 1997.
IN 72 YEARS, AND THE BEST THEY COULD COME UP WITH WAS 177 CASES.
No wonder that a physical therapist wrote that crappy research.
CHECK THIS OUT:
According to a 1995 U.S. iatrogenic report, "Over a million patients are injured in U.S. hospitals each year, and approximately 280,000 die annually as a result of these injuries.
ALSO CHECK THIS OUT:
"Since Americans spend so much money on health care, they should be getting a high quality of care, right? Unfortunately, that's not the case. Of the 783,936 annual deaths due to conventional medical mistakes, about 106,000 are from prescription drugs, according to Death by Medicine. That also is a conservative number. Some experts estimate it should be more like 200,000 because of underreported cases of adverse drug reactions."
YES, I CHOOSE CHIROPRACTIC!
Try reading this first http://www.garynull.com/articles/BigPharma102009Final.pdf
@Chris Pickard,
There is no context for your post. I venture to guess you meant to show wrongdoing in medicine. Many years ago a bank robber (Willie Sutton)was asked why he robbed banks and he replied "That's where the money is." Similarly, big corporations are sued because they have money. Law suits against quacks (chiropractors, homeopaths, etc.) are less spectacular.
In the USA, chiros are often indicted for insurance fraud. However, the chiropractors main source of income is fraud that involves 1) annual spinal checkups, 2) monthly maintenance adjustments, 3) pediatric treatments, 4) unnecessary x-rays; to cite a few. Too few of their customers ever recognize those crimes.
Another reason that fewer suits involve quacks is that there are very few of you compared to real, health professionals. In addition, most people who are really ill know to go to health professionals where the outcomes may not be the best because the conditions are serious and genuine treatments always entail more risk than mere massage and hand-holding empathy. (Except for the risk of delaying needed medicine by people going to quacks; which is always a danger.)
As far as the previous commenter on the incidence of strokes after cervical spine manipulation: we have no idea how many go unreported due to unexplained death or lack of suspicion. When neurologists started asking stroke patients about neck manipulation, the correlation became more apparent.
You also get sued if you do wrong - which happens a lot if you're a pharma company - I mean come on 132,000 times!
As an avid reader of all the medical journals I could get my hands on at chirorpactic college I quickly became aware that the same study could be interpreted by different people in totally opposite ways - depending on thier bias.
It is well known that we humans make our decisions emotionally and justify it later with logic - so we think we came to a logical conclusion.
What I can tell you from my own experience is that over the past 7 years I've treated 3000 people, none of whom have died of a stroke after being adjusted. I have however had 4 hospitalised for serious side effects to the medical drugs they were taking - which I had diagnosed 2 weeks before the doctors decided to take them off the meds to see if they got better!
I have also lost one patient to warfarin. It was about the sadest thing I've ever seen.
I have got 2 people off morphine patches. Seen blood pressure lowered in a few, and reversed 'diabetes' in three (not with chiropractic I might add).
I have also seen plenty of people come to chiropractic as they can't tolerate pain killers.
I'm not bashing medics, I'm just trying to get across that chiropractic is not as dangerous as Ernst tries to make out.
I believe one of Ernst's research papers was based on ringing up neurologists, asking them if they'd seen anyone with stroke, then asking them if those people may have seen a chiropractor. There was no reference to any medical notes.
Out of the 100 or so chiropractors I know, only one has seen a patient have a possible stroke after. I say possible as she was ok within a few minutes.
We chiropractors are very concerned about these possible problems and are always on the look out - but the fact is that in reality it is very, very rare.
We are also taught to refer when needed, and you may be surprsied to know that we have more training in orthopaedics and neurology than GP's do.
To all chiropractic skeptics I say come in to a clininc for a day and interview the people. We can't help everyone, but we do help a lot more than current evidence reveals.
Chris Pickard, thank you for your comments.
You say that over the past seven years you have treated 3,000 people, “none of whom have died of a stroke after being adjusted”. How do you know that? How do you know that patients that you’ve never seen again haven’t had a stroke as the result of being “adjusted” by you? Here’s the problem:
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“Sometimes the damage is immediate and the patient collapses on the chiropractor’s table. Sometimes mild symptoms start immediately and progress after the patient leaves the chiropractor’s office. Sometimes the tear is a small one and it clots over; then days later the clot breaks loose, travels to the brain and causes a delayed stroke. By this time, the patient may not connect his sudden collapse to the previous visit to the chiropractor...How often can a stroke be attributed to neck manipulation? We really don’t know. Estimates have varied from one in ten million manipulations to one in 40,000. I should clarify that only one specific type of stroke, basilar stroke, has been linked to chiropractic. It has been estimated that about 20% of all basilar strokes are due to spinal manipulations. This would work out to about 1300 a year in the U.S. But we just don’t know, because it has not been properly studied. Carotid artery strokes have also been reported after chiropractic treatments. Chiropractors do not follow up on every patient. Patients who have delayed strokes may never see their chiropractor again, so chiropractors would naturally tend to underestimate the risk. Many of these diagnoses are missed because the vertebral arteries are not typically examined on autopsy.”
http://www.sciencebasedmedicine.org/?p=94
You say you are not bashing medics, but just trying to get across that “chiropractic is not as dangerous as Ernst tries to make out”. Unfortunately, however, you cannot escape the fact that a responsible risk/benefit assessment for chiropractic spinal manipulation is largely unfavourable when there are other equally effective, cheaper, more convenient, and safer options available. That assessment would also include chiropractic spinal manipulation for back pain for the reason given in the quote below (which is lifted from a critique of the recently released (UK) NICE guidelines for low back pain):
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“…serious complications occur mostly (not exclusively) after upper spinal manipulation. So the guideline authors felt that they could be excluded. This assumes that a patient with lower back pain will not receive manipulations of the upper spine. This is clearly not always the case. Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them. And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain”.
[Ref: Ernst, E. Spinal manipulation for the early management of persistent non-specific low back pain - a critique of the recent NICE guidelines, Int J Clin Pract, 18th August 2009. Reprints available from author.]
http://tinyurl.com/y8dmwcs
Supporting the quotes above are the opinions of evidence-based chiropractor, and author, Samuel Homola:
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“While manipulation of any kind has the potential to cause injury, stroke caused by neck manipulation is of greatest concern. Risk must always be weighed against benefit when upper neck manipulation is considered. Risk of stroke caused by neck manipulation is statistically low, but the risk is serious enough to outweigh benefit in all but a few rare, carefully selected cases...All things considered, manual rotation of the cervical spine beyond its normal range of movement is rarely justified. The neck should never be manipulated to correct an asymptomatic “chiropractic subluxation” or an undetectable “vertebral subluxation complex” for the alleged purpose of restoring or maintaining health or to relieve symptoms not located or originating in the neck. There is no evidence that such subluxations exist.”
http://www.sciencebasedmedicine.org/?p=1037
Finally, there is no need for “chiropractic skeptics” to go to a chiropractic clinic for a day and interview the people. All that is required is for us to read what the science tells us – as pointed out in the conclusions of this recent review:
http://www.chiroandosteo.com/content/17/1/10
Hello again Blue_Wode,
I know that none of my patients has died of stroke from cervical manipulation as we try and keep in regular contact with even our past patients - mainly to asses long term effectiveness of treatment. Also, practicing in a village setting means we pretty much know what's going on - similar to many chiropractic, osteopathic and medical practices.
Had a look through your links - amazing how many times the reasearch comes back to that Ernst fellow. I checked out a few of the references especially in the Paediatric review and must admit I was wanting to learn more about the individual cases - such as who did the manipulation? In chiropractic we are very gentle with children - often no more than a 'nudge'.
Here are some references that found completley different results about cervical spine adjustments in children (probably as they where much more gentle than the ones that caused the tragedies in the paper you referenced).
And a bit of background to as to why we should be treating children (when indicated).
Paediatrics
Jensen, E. Learning with the body in mind. 2000
“What the developing brain needs for successful movement and cognitive growth is sufficient activation of this motor-cerebellar-vestibular system. Without it, problems in learning can arise, which include attention deficits, reading problems, emotional disregulation, weak memory skills, slow reflexes, lack of impulse control, and impaired or delayed writing skills.”
Jensen, E. Brain-Based Learning: The new science of teaching and training. 2000
“Amazingly, the part of the brain that processes movement is the same part of the brain that processes learning.”
Restak, R.M. The Brain: The last frontier. 1979
Reports the findings of Dr Frank Pederson, Chief of the Section on Parent-Child Interaction of the National Institute of Child Health and Development. Comparing the effects of visual, auditory and movement stimulation on mental and psychomotor development, found that movement had the broadest, most far reaching positive effects.
The above three pieces of work establish the basis for movement being of the utmost importance for infant health and development. The next studies clearly demonstrate the roll that chiropractic can play.
Guttman G. Blocked atlantal nerve syndrome in babies and infants. Manuelle Medizin. 1987, 25
Reports on the examination and adjustment of more than 1000 infants with ‘atlas blockage’ or as chiropractors would call it – subluxation.
The symptoms of ‘atlas blockage’ ranged from, “central motor impairment and development through diencephalic impairments of vegetative regulatory systems to lowered resistance to infections, especially to ear, nose and throat infections.”
Also mentions the work of a colleague, Frymann, who examined 1250 new born babies. 211 suffered vomiting, hyperactivity and sleeplessness. Examination revealed ‘cervical strain’ in 95% of this symptomatic group. Manipulation then , “frequently resulted in immediate cessation of crying, muscular relaxation and sleepiness”.
Conclusions: 80% of children are not in autonomic balance, that the upper cervical spine should be examined and, if required, treated with specific manipulation, because, “the success of adjustment overshadows every other type of treatment.”
Biedermann H. Kinematic imbalances due to suboccipital strain in newborns. Manuel Medicine 1992; 6
600 babies with a variety of problems including postural asymmetries, motor problems (including torticollis) , loss of appetite, neck sensitivity, fevers of unknown origin and other central nervous system disorders.
Results, “All but one of our little patients treated only with manipulation of the upper cervical spine developed satisfactorily.” No complications.
“The immense pathogenic potential of the proprioceptive afferents of the suboccipital region has until now been widely underestimated.”
Jesper et al. The short term effect of spinal manipulation in the treatment of infantile colic: A randomized controlled clinical trial with a blinded observer. JMPT 1999; 22 (8)
This, and an earlier study in 1989 found, specific, finger tip adjustments to the spine relieved colic symptoms.
The Danish health authorities, already being familiar with the safety and effectiveness of chiropractic for adults, picked up on this study and instructed nurses to recommend chiropractic care for babies suffering from colic.
(As an aside, Denmark’s progressive implementation of chiropractic and a rehabilitation program have lead it to be the ONLY country to be successfully managing chronic low back pain)
As to the point you made about there being safer and cheaper methods (for pain relief) - yes of course there is - ice, heat, massage, home exercises, and of course doing nothing! Pain killers I would argue that although cheaper, they may not be safer. The thing is though, most people seek out a chiropractor or osteopath because all that has failed. Very few come to us before trying the above.
Best of Health
Chris
Chris,
You cite some old papers on colic, here is a recent review: Husereau D, Clifford T, Aker P, Leduc D, Mensinkai S. Spinal manipulation for infantile colic.
Ottawa: Canadian Coordinating Office for Health Technology Assessment; 2003. Technology report no 42.
"Conclusions
• There is no convincing evidence that spinal
manipulation alone can affect the duration of
infantile colic symptoms.
• The effect of spinal manipulation on sleep
time, parental anxiety, quality of life and
number of colic diagnoses could not be
determined using available evidence.
• The potential harm from the spinal
manipulation of infants with colic could not be
determined using the evidence available from
controlled trials."
I have previously researched the literature on this topic and those are the proper conclusions.
Your references to Jensen, E. 2000 do not seem to cite medical literature. Ditto for Restak, R.M. 1979. Then you cite articles in Manuelle Medizin which, apparently, does not value randomized, blinded, controlled studies. Practitioners in a specialty rely on original literature, not books.
I have been interested for more than 30 years, and I have not seen chiropractic literature that supports any of their claims (except, tht you may be as effective as a masseur for low back pain).
You argue that you keep track of your 3000 customers; but you don't need to lose track of very many for you to be inflicting unnecessary suffering from ineffective "treatments."
@ Chris Pickard
Thank you for your reply.
You say that you "know" that none of your patients has died of stroke from cervical manipulation because you "try" and keep in regular contact with your past patients. If you really do keep in regular contact with every single patient who’s had their neck manipulated by you then that is commendable, but clearly your sole vigilance doesn’t make neck manipulation a safe or recommendable treatment as it doesn’t exclude any rare events experienced by patients of other chiropractors who are not so conscientious. I would also add that keeping in some sort of sporadic contact with patients seems to be a popular chiropractic marketing strategy - i.e. it helps to reactivate and retain patients (which can only be a good thing for chiropractors in the UK as most of them work in private practice).
It’s interesting that you say that chiropractors “are very gentle with children - often no more than a 'nudge'”, because judging by the following three videos, that doesn’t seem to be the case. Just look at the reactions of the children:
http://www.youtube.com/watch?v=5QQk_Acejjw
http://www.youtube.com/watch?v=JrXAeWtR_8M
http://www.youtube.com/watch?v=T5HMKrdrlAU
As for your references, which give completely different results about cervical spine adjustments in children, they are irrelevant. Systematic reviews, most of which are cited above, are where the real evidence lies.
Regarding your contention that pain killers may not be a safer treatment option, it’s worth remembering that in the case of NSAIDs, a true comparison would have to take into account the following:
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"No prospective randomized trial conclusively demonstrates that chiropractic management reduces the incidence of serious NSAID complications, such as fatal gastrointestinal bleeding. NSAIDs taken at recommended doses for a short time are generally very low-risk for appropriately selected patients — particularly the relatively young not on corticosteriods, anticoagulants, alcohol or tobacco and without a history of ulcers or severe comorbid illness.
Many patients continue to take NSAIDs while undergoing spinal manipulation. Moreover, spinal manipulation can frequently cause an exacerbation of pain, which might cause some patients to increase or initiate NSAID therapy. [Ernst E. Prospective investigations into the safety of spinal manipulation. Journal of Pain and Symptom Management, 21(3): 238-242, March 2001].
Herbal recommendations seem to be common among DCs; some remedies have actions similar to NSAIDs, while others directly affect bleeding per se . A recent set of reports by the North American Spine Society includes an 18-page reference chart listing approximately 70 herbs with their uses, potential side effects, and (known) potential interactions."
http://www.chirobase.org/18CND/03/03-03.html
It’s also worth remembering that packets of NSAIDs contain patient information leaflets detailing risks. However, it is evident that not all chiropractors warn patients about the risks associated with their manipulative treatments. See here http://tinyurl.com/y89x4lh and here
http://tinyurl.com/6ajn5d
I would also venture that because the rate of people taking NSAIDs is bound to be much higher than those receiving spinal adjustments, that NSAIDs are likely to be far safer. In addition to that, they have been proven to work. More here:
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"It is, of course, important to present any risk-benefit assessment fairly and in the context of similar evaluations of alternative therapeutic options. One such option is drug therapy. The drugs in question—non-steroidal anti-inflammatory drugs (NSAIDs)—cause considerable problems, for example gastrointestinal and cardiovascular complications. Thus spinal manipulation could be preferable to drug therapy. But there are problems with this line of argument: the efficacy of NSAIDs is undoubted but that of spinal manipulation is not, and moreover, the adverse effects of NSAIDs are subject to post-marketing surveillance while those of spinal manipulation are not. Thus we are certain about the risks and benefits of the former and uncertain about those of the latter. Finally, it should be mentioned that other therapeutic options (e.g. exercise therapy or massage) have not been associated with significant risks at all."
http://jrsm.rsmjournals.com/cgi/content/full/100/7/330
So, currently, it seems the bottom line is that since other equally effective, more convenient, cheaper, and safer options are available, it would be unethical for chiropractors to administer any type of spinal manipulation to a patient unless that patient still consented to treatment after being informed of the associated risks and all other options available.
You also say that most people seek out a chiropractor or osteopath because all that has failed. In that case, it could be that you are simply serving as an expensive distraction whilst their ailments run their natural courses. For example, a comparison of physical therapy, chiropractic manipulation, and the provision of an educational booklet for the treatment of patients with low back pain arrived at the following conclusion:
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"…the McKenzie method of physical therapy and chiropractic manipulation had similar effects and costs, and patients receiving these treatments had only marginally better outcomes than those receiving the minimal intervention of an educational booklet. Whether the limited benefits of these treatments are worth the additional costs is open to question."
http://tinyurl.com/ya7hsfe
Also, when you consider the views of Edzard Ernst (an impartial, expert, research scientist) on the BEAM trial (which estimated the effect of adding exercise classes, spinal manipulation delivered in NHS or private premises, or manipulation followed by exercise to "best care" in general practice for patients consulting with back pain) they support the suggestion that time and reassurance play the greatest role in a patient’s recovery:
http://www.bmj.com/cgi/eletters/bmj.38282.669225.AEv1#88126
Regarding your contention that pain killers may not be a safer treatment option, Law School it’s worth remembering that in the case of NSAIDs, a true comparison would have to take into account the following. University| Associate Degree
For example, a comparison of physical therapy, chiropractic manipulation, and the provision of an educational booklet for the treatment of patients with low back pain arrived at the following conclusion:Online Diploma
.., chiropractic covers a big benefits in terms of health.. if this one is being practice by a good hand.. this procedure will take along run.. :)
Thanks for the Info.. It will help net surfers like me and specially those who wants to try chiropractic practices