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Dismantling the chiropractic claims of the BCA, GCC and others

Martin 20 May 2009 syndicated No Comment

ResearchBlogging.org [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.
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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; the UK statutory regulatory body, the General Chiropractic Council (GCC) (created to protect patients and set standards of chiropractic education, conduct and practise), does also. 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 resort to confusing the two approaches in order to give all 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.

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 looks suspiciously like they have been 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?

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)
http://ph-ms.ouhsc.edu/ah/rehab/kinsinger.wmv

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)
http://www.youtube.com/watch?v=5wCicEGlRXk

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

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