In my five years in the blogosphere, two years blogging for SBM, and over a decade in Internet discussion forums about medicine and “alternative” medicine, I’ve learned a few things. One thing that I’ve learned is that one of the biggest differences between those whose world view is based on science and who therefore promote science-based medicine and those promoting pseudoscience, quackery, and anti-science is that science inculcates in its adherents a culture of free, open, and vigorous debate. Indeed, to outsiders, this debate can seem (and sometimes is) vicious. In other words, if you’re going to be a scientist, you need to have a thick skin because you will have to defend your hypotheses and conclusions, sometimes against some very hostile other scientists. That same attitude of a Darwinian struggle between scientific ideas, with only those best supported by evidence and with the most explanatory power surviving, is a world view that those not steeped in science have a hard time understanding.
Among those who don’t understand science, few have a harder time with the rough-and-tumble debate over evidence and science that routinely goes on among scientists than those advocating pseudoscience. Indeed, in marked contrast to scientists, they tend to cultivate cultures of the echo chamber. Examples abound and include discussion forums devoted to “alternative” medicine like CureZone, where never is heard a discouraging word — because anyone expressing too much skepticism about the prevailing view on such forums invariably finds himself first shunned by other members of the discussion forums and then, if he persists, booted from the forum by the moderators. In marked contrast, on skeptical forums, most of the time almost anything goes. True, the occasional supporter of woo who finds his way onto a skeptical forum will face a lot of criticism, some of it brutal. However, rarely will such a person be banned, unless he commits offenses unrelated to his questioning of scientific dogma, such as insulting or abusive behavior towards other forum participants or trolling. Such people may annoy the heck out of us skeptics sometimes, but on the other hand, they do actually from time to time challenge us to defend our science and prevent us from becoming too complacent. Indeed, that’s what I like about skeptics and being a scientist. Nothing or no one is sacred.
An article written by 3 chiropractors and a PhD in physical education and published on December 2, 2009 in the journal Chiropractic and Osteopathy may have sounded the death knell for chiropractic.
The chiropractic subluxation is the essential basis of chiropractic theory. A true subluxation is a partial dislocation: chiropractors originally believed bones were actually out of place. When x-rays proved this was not true, they were forced to re-define the chiropractic subluxation as “a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.” Yet most chiropractors are still telling patients their spine is out of alignment and they are going to fix it. Early chiropractors believed that 100% of disease was caused by subluxation. Today most chiropractors still claim that subluxations cause interference with the nervous system, leading to suboptimal health and causing disease.
What’s the evidence? In the 114 years since chiropractic began, the existence of chiropractic subluxations has never been objectively demonstrated. They have never been shown to cause interference with the nervous system. They have never been shown to cause disease. Critics of chiropractic have been pointing this out for decades, but now chiropractors themselves have come to the same conclusion. (more…)
The last two weeks have brought good news to those who seek to hold chiropractic to the standard of evidence and science-based medicine.
In the first bit of good news, on October 14th Simon Singh was granted permission to appeal the High Court ruling on meaning of the term “bogus” within his original article. I’m sure most readers of this blog are familiar with Simon Singh’s legal battle with the British Chiropractic Association (BCA) regarding an article in The Guardian entitled “Beware the Spinal Trap.” We’ve covered it several times over the last year and will continue to do so as the case progresses. The nuances of the British legal system (or any legal system for that matter) are beyond my ken, and are far better explained by Jack of Kent here. The take-home point is that gaining permission to appeal the ruling on meaning was virtually essential if Simon were to have any real chance of winning this lawsuit.
Even if the BCA should win its lawsuit for libel against Singh, it seems likely to be something of a pyrrhic victory. After all, in the year since this story began, we’ve been belatedly provided with the BCA’s best evidence in support of chiropractic’s efficacy, and promptly treated to its subsequent evisceration. (more…)
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.
When the RAND (Research and Development) organization published its review of the literature on cervical spine manipulation and mobilization in 1996, it concluded that only about 11.1% of reported indications for cervical spine manipulation were appropriate and that stroke and other serious complications occurred about 1.46 times per one million neck manipulations.1 In the same year, after examining 183 cases of vertebrobasilar stroke that occurred from 1934 through 1994 following neck manipulation, the National Chiropractic Mutual Insurance Company (NCMIC) concluded that “It has to be accepted that VBS [vertebrobasilar stroke] following SMT [spinal manipulative therapy] does occur.”2
Chiropractic originated in 1895 when D.D. Palmer claimed to have restored deaf janitor Harvey Lillard’s hearing by manipulating his spine. This makes no anatomical sense, and few if any chiropractors claim to be able to reverse deafness today. But now a chiropractic website is attempting to vindicate D. D. Palmer. They list deafness among a long (wrong) list of “Conditions That Respond Well to Chiropractic”
They list 6 supporting studies. Three are case reports, two are case series, and one is a review of the literature that is labeled in its title as “A Search to Validate” D.D. Palmer. (more…)
EDITOR’S NOTE: Dr. Atwood, who would normally be scheduled to post today, is on vacation. Consequently, we are publishing the following guest post by Samuel Homola, D.C., a retired chiropractor who limited his practice to science-based methods and spoke out against the irrational and abusive practices of his colleagues. He is the author of Inside Chiropractic and Bonesetting, Chiropractic, and Cultism and co-author with Stephen Barrett of the skeptical Chirobase website, a division of Quackwatch) .
In 1895, Daniel David Palmer, a magnetic healer, announced that “95 percent of diseases are caused by displaced vertebrae; the remainder by luxations of other joints.” He opened the first chiropractic school in Davenport, Iowa—the Palmer Infirmary, which offered a three-week course of instruction.
In 1906, D.D. Palmer’s son, Bartlett Joshua Palmer, a 1902 graduate of the Palmer Infirmary, took over his father’s school. In 1924, claiming that “subluxation” of any vertebra would cause disease by compressing nerves in the intervertebral foramina, B.J. Palmer introduced the “Neurocalometer,” a thermocouple device guaranteed to locate nerve-pinching vertebral subluxations. Chiropractors were told that if they did not use this “infallible” device to measure heat differentials on the skin over the spine, they could not competently locate and adjust a subluxation. But the Neurocalometer was not for sale. Chiropractors were forced to lease the instrument and then pay a monthly rent.
In the early 1930s, after nearly three decades of teaching that subluxations anywhere in the spine can cause disease, B.J. Palmer announced that he had found the one and only cause of disease: subluxation of the atlas. Palmer concluded that subluxation of a spinal vertebra below the axis was not possible because vertebrae below that level were bound together by intervertebral discs and interlocking joints. Students at the Palmer School of Chiropractic were not permitted to adjust the spine below the axis until 1949 when full-spine techniques were once again included in the course of instruction.
B.J. Palmer’s “hole-in-one” (HIO) technique for adjusting the atlas and the axis remained popular among certain factions of the chiropractic profession. According to the 2005 edition of Job Analysis of Chiropractic, published by the National Board of Chiropractic Examines, 25.7% of practicing chiropractors include the “Palmer upper cervical/HIO” technique in their adjustive procedures. (more…)
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.
In discussions of that bastion of what Harriet Hall likes to call “tooth fairy science,” where sometimes rigorous science, sometimes not, is applied to the study of hypotheses that are utterly implausible and incredible from a basic science standpoint (such as homeopathy or reiki), the National Center of Complementary and Alternative Medicine (NCCAM), I’ve often taken Senator Tom Harkin (D-IA) to task, as have Drs. Novella, Lipson, and Atwood. That’s because Senator Harkin is undeniably the father of that misbegotten beast that has sucked down over $2.5 billion of taxpayer money with nothing to show for it. NCCAM is the brainchild of Senator Harkin, who foisted it upon the National Institutes of Health not because there was a scientific need for it or because scientists and physicians cried out for it but rather because Senator Harkin, who believed that alternative medicine had healed a friend of his, wanted it, and he used his powerful position to make it happen, first as the Office of Unconventional Therapies, then as the Office of Alternative Medicine, and finally as the behemoth of woo that we know today as NCCAM. The result has included a $30 million trial of chelation therapy in which convicted felons were listed among the investigators and a totally unethical trial of the Gonzalez therapy for pancreatic cancer. It’s not for naught that Wally Sampson called for the defunding of NCCAM, as have I and others. Not surprisingly, alternative medicine practitioners are appalled at this idea.
Most recently, Harkin has been most disturbed by the observation that NCCAM’s trials have all been negative, going so far as to complain that NCCAM hasn’t produced any positive results showing that various alternative therapies actually work. This is, of course, not a surprise, given that vast majority of the grab bag of unrelated (and sometimes theoretically mutually exclusive) therapies are based on pseudoscience. One of the only exceptions is the study of herbal remedies, which is a perfectly respectable branch of pharmacology known as pharmacognosy. Unfortunately, as David Kroll showed, in NCCAM the legitimate science of pharmacognosy has been hijacked for purposes of woo. Meanwhile, earlier this year, Senator Harkin hosted a hearing in which Drs. Dean Ornish, Andrew Weil, Mehment Oz, and Mark Hyman (he of “functional medicine“) were invited to testify in front of the Senate. Add to that other powerful legislators, such as Representative Dan Burton (R-IN), trying to craft legislation in line with his anti-vaccine views and pressure the NIH to study various discredited hypotheses about vaccines and autism. Clearly, when it comes to quackery, there are powerful legislative forces promoting pseudoscience and studies driven by ideology rather than science.
Simon Singh is a science journalist who last year wrote an article in the Guardian critical of the British Chiropractic Association (BCA) for promoting chiropractic treatment for certain childhood ailments. Singh characterized these treatments as “bogus” because they lack evidence to back up claims for clinical efficacy. The BCA responded by suing Singh for libel. In the English court system the person being sued for libel is essentially guilty until proven innocent, and even successfully defending oneself can be ruinously expensive. Therefore suing for libel in English court is a very successful strategy for silencing critics.
This case resulted in a bit of a backlash against the BCA, who were accused of silencing legitimate and very necessary public scientific debate regarding the safety and efficacy of medical interventions. The BCA could have simply responded by providing evidence to back up their claims, and the Guardian even offered them space to do so, but instead they sued.
Part of this backlash is a movement, supported by many scientific organizations, to keep libel laws out of science.
Last week I reviewed the history of chiropractic and discussed issues relating to its underlying claims and treatments for non-musculoskeletal indications. Today I will focus on chiropractic for back pain and similar indications.
There is evidence to support the very narrow indication of spinal manipulation for the symptomatic management of acute uncomplicated lower back strain. The good news for chiropractors is that this is a very common condition and does not respond well to conventional management – actually all treatments: medical management, physical therapy, manipulation, and even just patient education, appear to be equally and quite modestly effective.
There is a body of clinical studies that are relevant to the question of manipulation for lower back strain. A review of this research was published in 1989 by the RAND corporation, an independent research group that put together a panel of both physicians and chiropractors to review the available research on manipulative therapy. They concluded that evidence from 22 studies supported the use of manipulative therapy for acute uncomplicated lower back pain (again – no real pinched nerves). It is important to understand, however, that they were referring to manipulative therapy, not chiropractic. In fact only 4 of the 22 studies mentioned included chiropractors. In the other studies the manipulative therapy was performed by physicians and physical therapists.