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Beware the Spinal Trap

Last year Simon Singh wrote a piece for the Guardian that was critical of the modern practice of chiropractic. The core of his complaint was that chiropractors provide services and make claims that are not adequately backed by evidence – they are not evidence-based practitioners. In response to his criticism the British Chiropractic Association (BCA) sued Simon personally for libel. They refused offers to publish a rebuttal to his criticism, or to provide the evidence Simon said was lacking. After they were further criticized for this, the BCA eventually produced an anemic list of studies purported to support the questionable treatments, but really just demonstrating the truth of Simon’s criticism (as I discuss at length here).

In England suing for libel is an effective strategy for silencing critics. The burden of proof is on the one accused (guilty until proven innnocent) and the costs are ruinous. Simon has persisted, however, at great personal expense.

This is an issue of vital importance to science-based medicine. A very necessary feature of science is public debate and criticism – absolute transparency.This is also not an isolated incident. Some in the alternative medicine community are attempting to assert that criticism is unprofessional, and they have used accusations of both unprofessionalism and libel as a method of silencing criticism of their claims and practices. This has happened to David Colquhoun and Ben Goldacre, and others less prominent but who have communicated to me directly attempts at silencing their criticism.

This behavior is intolerable and is itself unprofessional, an assault on academic freedom and free speech, and anathema to science as science is dependent upon open and vigorous critical debate.

What those who will attempt to silence their critics through this type of bullying must understand is that such attempts will only result in the magnification of the criticism by several orders of magnitude. That is why we are reproducing Simon Singh’s original article (with a couple of minor alterations) on this site and many others. Enjoy.

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Some practitioners claim it is a cure-all, but the research suggests chiropractic therapy has mixed results – and can even be lethal, says Simon Singh.

You might be surprised to know that the founder of chiropractic therapy, Daniel David Palmer, wrote that “99% of all diseases are caused by displaced vertebrae”. In the 1860s, Palmer began to develop his theory that the spine was involved in almost every illness because the spinal cord connects the brain to the rest of the body. Therefore any misalignment could cause a problem in distant parts of the body.

In fact, Palmer’s first chiropractic intervention supposedly cured a man who had been profoundly deaf for 17 years. His second treatment was equally strange, because he claimed that he treated a patient with heart trouble by correcting a displaced vertebra.

You might think that modern chiropractors restrict themselves to treating back problems, but in fact some still possess quite wacky ideas. The fundamentalists argue that they can cure anything, including helping treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying – even though there is not a jot of evidence.

I can confidently label these assertions as utter nonsense because I have co-authored a book about alternative medicine with the world’s first professor of complementary medicine, Edzard Ernst. He learned chiropractic techniques himself and used them as a doctor. This is when he began to see the need for some critical evaluation. Among other projects, he examined the evidence from 70 trials exploring the benefits of chiropractic therapy in conditions unrelated to the back. He found no evidence to suggest that chiropractors could treat any such conditions.

But what about chiropractic in the context of treating back problems? Manipulating the spine can cure some problems, but results are mixed. To be fair, conventional approaches, such as physiotherapy, also struggle to treat back problems with any consistency. Nevertheless, conventional therapy is still preferable because of the serious dangers associated with chiropractic.

In 2001, a systematic review of five studies revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches. These are relatively minor effects, but the frequency is very high, and this has to be weighed against the limited benefit offered by chiropractors.

More worryingly, the hallmark technique of the chiropractor, known as high-velocity, low-amplitude thrust, carries much more significant risks. This involves pushing joints beyond their natural range of motion by applying a short, sharp force. Although this is a safe procedure for most patients, others can suffer dislocations and fractures.

Worse still, manipulation of the neck can damage the vertebral arteries, which supply blood to the brain. So-called vertebral dissection can ultimately cut off the blood supply, which in turn can lead to a stroke and even death. Because there is usually a delay between the vertebral dissection and the blockage of blood to the brain, the link between chiropractic and strokes went unnoticed for many years. Recently, however, it has been possible to identify cases where spinal manipulation has certainly been the cause of vertebral dissection.

Laurie Mathiason was a 20-year-old Canadian waitress who visited a chiropractor 21 times between 1997 and 1998 to relieve her low-back pain. On her penultimate visit she complained of stiffness in her neck. That evening she began dropping plates at the restaurant, so she returned to the chiropractor. As the chiropractor manipulated her neck, Mathiason began to cry, her eyes started to roll, she foamed at the mouth and her body began to convulse. She was rushed to hospital, slipped into a coma and died three days later. At the inquest, the coroner declared: “Laurie died of a ruptured vertebral artery, which occurred in association with a chiropractic manipulation of the neck.”

This case is not unique. In Canada alone there have been several other women who have died after receiving chiropractic therapy, and Edzard Ernst has identified about 700 cases of serious complications among the medical literature. This should be a major concern for health officials, particularly as under-reporting will mean that the actual number of cases is much higher.

If spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.

Simon Singh is a science writer in London and the co-author, with Edzard Ernst, of Trick or Treatment? Alternative Medicine on Trial. This is an edited version of an article published in The Guardian for which Singh is being personally sued for libel by the British Chiropractic Association.


Posted in: Chiropractic, Science and Medicine, Science and the Media

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14 thoughts on “Beware the Spinal Trap

  1. Steve S says:

    Wonderful! I have read about Simon plight and have signed the petition in support of him. I had a chiropractor in my home town have published in our local paper about the benefits of manipulation in children. I wrote an article refuting that article using the chiropractors own literature. Yes, there are some that are trying to use experiments to prove that it works. I got an angry response from the chiropractors husband saying I didn’t understand the “science” of chiropractic. No other responses.

  2. David Gorski says:

    A cached version of the original, unscrubbed article can be found here.

    The allegedly libelous passage has been reposted by Jack of Kent and others:

    The British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence. This organisation is the respectable face of the chiropractic profession and yet it happily promotes bogus treatments.

  3. Canucklehead says:

    Simon’s problems here lie with the definition of the word ‘bogus’ which the judge (Justice Eady) in this matter decided meant ‘with intent to defraud’ This is the strongest possible meaning of the word and would indicate that the chiropractors know there is no basis for their treatments and deliberately set out to defraud the public. While I have no time for chiropractors I’m quite sure that many of them actually belive that what they do is genuine and helpful. For Simon to prove that they as a whole set out to defraud the public is a herculean task, hopefully his appeal of Justice Eady’s definition will be successful.

  4. David Gorski says:

    I’m not optimistic. British courts rarely overturn a ruling on meaning, even if it’s as ridiculous as Judge Eady’s. I hope Singh can afford to take this all the way through the British legal system and then to the European Court of Human Rights, because that’s what he’s probably going to have to do.

    I’d love to be wrong about this, of course.

  5. DevoutCatalyst says:

    “…While I have no time for chiropractors I’m quite sure that many of them actually believe that what they do is genuine and helpful…”

    This is yet another opportunity for them to learn.

    You can’t shelter yourself from knowledge and intend to grow into anything other than an amateur human being. The CAM professions bring this arrested development upon themselves. A pity, truly.

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  7. Dr Benway says:

    Didn’t the BCA essentially demonstrate awareness of their own bogosity when they advised members to delete their web sites?

    If I recall (and I admit my memory is a bit fuzzy), the BCA were worried that the usual unsupported claims on such sites might prove embarassing in light of the Singh case.

    The inadvertent confession gave me teh lulz at the time I read about it.

  8. Joe says:

    @ Dr Benway,

    I have heard that the BCA told members to take down their web-sites. I have seen the letter (on the Net) from Mctimony Chiro Assoc telling their people to do so, and the fact that many did supports the authenticity of the letter.

    In 2006, the BCA published a brochure titled “Happy Families” http://www.ebm-first.com/?cat=33 which contains the bogus claims they make about treating childhood ailments. That brochure is no longer on their web-site.

    It is also amusing that the BCA’s original plethora of information supporting pediatric chiro (cited/linked above) ran to 29 references, padded with irrelevant articles. More recently, they furnished a list of 19 papers, and it was still padded with nonsense. http://www.bmj.com/cgi/content/full/339/jul08_4/b2766

  9. Joe says:

    http://www.chiropractic-uk.co.uk/gfx/uploads/textbox/Singh/BCA%20Statement%2031st%20July%202009.pdf

    The British court of appeals has refused to hear Singh’s appeal of the court’s bogus definition of “bogus.” Apparently, there is a second “appeal route” in the UK; which may also be barred by the decision. Details of the refusal are not yet available. http://jackofkent.blogspot.com/2009/07/simon-singh-loses-first-attempt-at.html After that, there is a European Court of Human Rights.

  10. David Gorski says:

    This does not surprise me. Jack of Kent’s been excellent and spot on all along in his commentary about this case, and he predicted that the odds were long that the Court of Appeals would reverse Judge Eady’s ruling.

    As I’ve said before here and elsewhere. If I lived in the U.K., I don’t know if I’d be blogging. Too risky.

  11. Joe says:

    A quick recap- Simon Singh wrote an Op-Ed piece saying the British Chiro Ass’n (BCA) saying they offered “bogus” treatments* and the BCA sued him for libel. The judge (Eady) in the case found Singh’s comments were meant as fact, not opinion, and that “bogus” meant fraudulent (as-in, chiros know their methods don’t work).

    He was “barred” from appealing Eady’s findings. Except, under British law, he could ask the higher court for permission to appeal.

    Last Wednesday (Oct. 14) the appeals court granted Singh permission to appeal Eady’s findings.

    Then, the spit hit the fan and we await the repercussions. The BCA posted a press-release saying that Singh had written a malicious attack on them. According to a lawyer involved peripherally with the case, the BCA has libeled Singh by saying he was “malicious” and now Singh can counter-sue. http://jackofkent.blogspot.com/2009/10/bca-defame-simon-singh.html In fact, the judge on Wednesday noted that malice was not involved. The BCA quickly changed the wording in the PR statement; but they were too late make it like it never happened.

    The lawyer has noted that it is up to Singh to decide how to proceed; but it gives him a good option.

    * Singh mentioned specific, bogus treatments (for colic, ear infections, etc.), not everything they do.

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