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The British Chiropractic Association Responds to Simon Singh

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.

Recently the BCA has responded to this backlash with a statement and a list of studies they claim provides the evidence Singh said was lacking. I won’t address their attempt at damage control, but rather focus on their response regarding the evidence. They write:

In the spirit of wider scientific debate, and having taken appropriate professional advice, the BCA has decided that free speech would be best facilitated by releasing details of research that exists to support the claims which Dr. Singh stated were bogus. This proves that far from being “not a jot of evidence” to support the BCA’s position, there is actually a significant amount.

They follow their statement with a list of 29 studies. This is a short reference list to support several individual medical claims, but actually it is a bloated list that contains many references that do not provide evidence for the claims of the BCA that Sign was criticizing. This is how the 29 references break down:

3 – Risks of NSAID medication
1 – Nature of evidence-based medicine
3 – opinion, chiropractic practice
1 – letter to editor
2 – review
2 – risks of chiropractic
8 – colic
3 – nocturnal enuresis
3 – otitis media
3 – asthma

Therefore, out of the 29 references, only 17 actually provide evidence for the efficacy claims for chiropractic for these four pediatric indications. When each indication is considered, the list of supporting studies is embarrassingly thin. They are also of very poor quality and, as we will see, cherry picked.

It should also be noted that the notion of spinal manipulation for medical issues, like a middle ear infection, is highly implausible. Such implausible claims should require robust clinical evidence before putting them into practice. The evidence presented by the BCA is far from robust, and when the totality of evidence is considered it is actually negative.

Colic

Of the 8 studies presented for colic, one is a preliminary assessment of cranial osteopathy for colic. In the past chiropractors have complained that studies of non-chiropractic forms of manipulation cannot be used to dismiss the efficacy of chiropractic. It is disingenuous of the BCA to pad their list of evidence for chiropractic by including a study of osteopathic manipulation. Two of the studies were case reports. One report is a response to a questionnaire, and there were three unblinded or single-blinded studies, and one uncontrolled study. Therefore, not one prospective, double-blind, placebo-controlled study is presented. All we are given is low grade evidence.

Also, the BCA left off the best designed study, which not surprisingly was negative. Olafsdottir et al (1) studied 86 infants with colic in a randomized controlled trial and found:

“Chiropractic spinal manipulation is no more effective than placebo in the treatment of infantile colic.”

How does the BCA justify omitting this study from their list?  Do they think that an open scientific discussion of evidence means presenting only the evidence that seems to support their position?

The BCA also neglected to reference a review of the evidence for chiropractic for colic by Hughes and Bolton (2) which concludes:

“The evidence suggests that chiropractic has no benefit over placebo in the treatment of infantile colic. However, there is good evidence that taking a colicky infant to a chiropractor will result in fewer reported hours of colic by the parents.”

Their conclusion was curious – chiropractic treatment for colic does not work but parents report that it does.  Ordinarily science-based practitioners would simply interpret such results as being consistent with a placebo effect alone.

What we see is the typical pattern of evidence for an ineffective treatment – low grade evidence showing an effect, but higher grade controlled evidence showing no effect above placebo. The bottom line is that existing evidence suggests that chiropractic manipulation is not effective in the treatment of colic. But the BCA cherry picked only the low grade evidence that supported their claim.

Asthma

Of the three asthma studies presented, two were of osteopathic manipulation and the third is a case series and pilot study. The two osteopathic studies were looking at markers of pulmonary function, and not clinical outcomes. Again, it is very telling that these three weak studies are all the BCA could come up with.

And again, the BCA left off their list the largest and most definitive study of chiropractic treatment for childhood asthma – the 1998 New England Journal of Medicine study (3). This was a large randomized controlled trial, which found:

In children with mild or moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit.

The pattern repeats again – the best data shows no effect from manipulation. It is my sincere contention that if the exact same evidence (even leaving out the lack of plausibility) existed for a medical treatment, it would be abandoned as a worthless dead end. At the very least, use would stop until further research were done. There might even be concerns about the ethics of further research given the negative evidence and lack of plausibility.

The BCA and chiropractors in general have simply ignored or dismissed the negative evidence of chiropractic for asthma and instead cherry pick the very low-grade evidence that seems to support what they want to claim. This makes chiropractic treatment for asthma “bogus.”

Otitis Media

There is precious little research into the treatment of acute otitis media (middle ear infection) with chiropractic adjustment. The three studies cited are all retrospective or uncontrolled. There are no double-blind placebo controlled studies – and therefore no reliable evidence upon which to base a clinical claim.

Nocturnal Enuresis

Again, we have three weak studies and nothing to defend the implausible claim that chiropractic treats nocturnal enuresis. One of the studies cited is by Reed et al, which concludes:

“The mean pre- to post-treatment change in the wet night frequency for the treatment group compared with the control group did not reach statistical significance (p = 0.067).”

In other words – this is a negative study. The comparison of treatment to control showed no statistically significant difference. There was a trend – but they are not reliable enough to serve as a basis for clinical conclusions. That is the whole point of statistical significance. This was a small study, so you can say that it was simply not powerful enough to detect an effect – but that still leaves us without evidence to support the claim for an effect.

A Cochrane review of the evidence regarding chiropractic and other alternative treatments for nocturnal enuresis concluded:

“There was weak evidence to support the use of hypnosis, psychotherapy, acupuncture and chiropractic but it was provided in each case by single small trials, some of dubious methodological rigour.”

Conclusion

The BCA’s list of evidence for these four clinical claims is not impressive.  The best they have to offer is a few weak and poorly designed studies. They also ignore larger better trials where available that are negative.

A more thorough assessment of the evidence for chiropractic treatment for asthma and colic reveals evidence for lack of efficacy. For otitis media and nocturnal enuresis there is a lack of evidence for efficacy.

Despite the state of the evidence, the BCA feels they are justified in promoting chiropractic for these pediatric indications. The reader can decide if the term “bogus” applies.

References:

1) Olafsdottir E, Forshei S, Fluge G, Markestad T. Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation. Arch Dis Child. 2001 Feb;84(2):138-41.

2) Hughes S, Bolton J. Is chiropractic an effective treatment in infantile colic? Arch Dis Child. 2002 May;86(5):382-4.

3) Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O’Shaughnessy D, Walker C, Goldsmith CH, Duku E, Sears MR. A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma. N Engl J Med. 1998 Oct 8;339(15):1013-20.

Posted in: Chiropractic

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53 thoughts on “The British Chiropractic Association Responds to Simon Singh

  1. Mojo says:

    In the past chiropractors have complained that studies of non-chiropractic forms of manipulation cannot be used to dismiss the efficacy of chiropractic. It is disingenuous of the BCA to pad their list of evidence for chiropractic by including a study of osteopathic manipulation.

    In the Advertising Standards Authority’s adjudication on BCA member Carl Irwin‘s claims to be able to treat IBS, colic and learning difficulties, the ASA noted:

    In relation to the chiropractic treatment of IBS we noted the evidence provided included a 2007 randomised controlled pilot study relating to osteopathy and another randomised controlled study where results involving the treatment of IBS with osteopathy were described as “promising”; we noted, however, that those studies referred to osteopathy, not chiropractic.

  2. Joe says:

    There is a link to news about the Singh case here http://www.ebm-first.com/?cat=60

    The case, in short was based on Singh’s remark that chiropractor’s haven’t a “jot” of evidence to support those “bogus” treatments. In early May, the judge announced that “bogus” means “fraudulent” which put Singh in the position of needing to show the chiropractors know their treatments are useless. Singh is currently appealing that definition. So far, he has spent 100,000 pounds and think it could reasonably cost 500,000 (1 million at the outside); which he can afford. Of course, if he wins the chiros have to reimburse him.

    After the judge saddled him with that bogus definition of “bogus,” a campaign to revise libel laws in the UK was begun; the petition quickly garnered 10,000 signatures. So, it became news and each article about the campaign made mention of the chiros trying to silence debate. Now the chiros are sniffing about being made to look bad when they are “victims.”

    More recently, two people searched the Net for UK chiros claiming to cure colic, asthma, etc. They archived the pages, and then filed complaints with various government agencies. In addition, they filed 529 complaints with the chiro regulatory board (GCC). As I understand it, the GCC is required to investigate each complaint.

    In response, at least one chiro association sent a panicked e-mail to its members telling them to stop distributing their literature, and take down their web sites. Also, they should not have anything that describe themselves as “doctor” unless it is clear that they are chiropractors. One wonders what they have to fear.

  3. perrys519 says:

    Very nice article explaining the evidence. For anyone who wishes to help with the “backlash”, I have composed a letter to be sent to Trading Standards as a follow-up to the original 250 complaints that went out. If you wish to be added as a signatory, please see the progress so far and join the Facebook group here: http://adventuresinnonsense.blogspot.com/2009/07/over-half-of-chiropractor-colic-web.html

  4. Blue Wode says:

    Great post.

    Quote:
    “Of the 8 studies presented for colic, one is a preliminary assessment of cranial osteopathy for colic. In the past chiropractors have complained that studies of non-chiropractic forms of manipulation cannot be used to dismiss the efficacy of chiropractic.”

    That is so true. Indeed, just yesterday, in a 5-page statement in response to an Australian television network’s news item on chiropractic, which featured the BCA v. Simon Singh case, the Chiropractors’ Association of Australia (CAA) declared the following:

    Quote:
    “The CAA is concerned that the Lateline report attempts to link one trial involving manipulation undertaken by physiotherapists as an equivalent to chiropractic spinal adjustments. Where is the evidence to prove that these are one and the same thing?”

    More…
    http://tinyurl.com/n8b887

  5. Blue Wode says:

    Re my post above – the first part of the Australian news segment (6th July 2009) can be read/viewed here,
    http://www.abc.net.au/lateline/content/2008/s2618495.htm

    and the second part, featuring the Simon Singh interview, can be viewed here:
    http://www.abc.net.au/news/video/2009/07/06/2618503.htm

  6. mjrobbins says:

    This is a good article, but I don’t understand why you don’t acknowledge the work of the many British bloggers working on this case. To not have a link to a single British science blogger when you’re discussing a statement that probably wouldn’t exist if it weren’t for the heat they generated is pretty poor imho.

  7. JMG says:

    Not that I don’t agree that spinal adjustment for asthma etc. is bogus, but how do you propose a properly blinded study involving violent physical manipulations?

  8. Mojo says:

    Here are a couple of sets of links, from Zeno’s Blog, to blog comments on this case and related issues:

    Who’s been blogging on chiroquacktic?

    Who’s been blogging on chiroquacktic? After the ‘plethora’.

  9. Blue Wode says:

    Another great round-up on links on the BCA v. Simon Singh case can be found here:
    http://godknowswhat.wordpress.com/2009/05/16/simon-singh-case-response-roundup/

  10. nj – no slight meant to the UK science bloggers who are doing a fine job keeping on top of this case. But this is not a news report on the Singh case – it is an analysis of the evidence presented by the BCA.

  11. mckenzievmd says:

    Excellent summary! One of the most difficult aspects of debating these topics with true believers is that they can always find publications to support their position, and it takes a lot of time and effort to go through the publications in detail to see why they don’t really say what their proponents claim they say. Thanks for doing the footwork for us all!

    The SkeptVet
    http://www.skeptvet.com
    http://skeptvet.com/Blog

  12. pmoran says:

    Might not the deliberate omission of negative studies and the inclusion of dross point to an element of knowing deception behind the BCA advertising? Someone should point this out to the British judges.

  13. Grimreapor says:

    Great post. I am still shocked at how badly they have done for damage control so far.

    Even better was the fact they gave articles on risks of NSAID’s… Must really be digging for some dirt there. Especially as there are some extremely useful ones. I speak from experience on this part.

    And pmoran
    ‘Might not the deliberate omission of negative studies and the inclusion of dross point to an element of knowing deception behind the BCA advertising? Someone should point this out to the British judges.’
    Like every alternative medicine group you could blame; stupidity, blatant ignorance and just delusion as well. It’s probably a combination.

  14. pmoran says:

    “Their conclusion was curious – chiropractic treatment for colic does not work but parents report that it does. Ordinarily science-based practitioners would simply interpret such results as being consistent with a placebo effect alone.”

    We have a condition which always gets better by itself, which is not damaging to the baby, and where the main problem is the concern of the parents and the stresses to which they are subject. It should be no surprise that ANY reassuring attention can seemingly serve satisfactorily as “medicine”.

    The main concern here is that chiropractors should be leaving baby’s necks alone! — period. Those necks are like jelly at this age and the notion that chiropractors can actually do anything useful to them simply reinforces a negative impression of chiropractic standards of common sense.

    There are safer and cheaper placebos, if that is deemed necessary in order to satisty some of the needs that parents typically bring into such consultations, such as the “do something!” imperative.

  15. daijiyobu says:

    BTW, paralleling ‘BCA / BCA member’ claims regarding the efficacy of using manipulation for serious pediatric conditions, other manipulators [!] make similar claims.

    On a recent plane ride to Nevada [wink-wink; looking forward to tomorrow, SBM bloggers!] I was reading over chapter 1 of Chaitow’s “Naturopathic Physical Medicine” (2008, ISBN 0443103909) [because I'm fascinated by the naturopaTHICK; attributed to NDs Chaitow, Zeff, Snider, Buratovich, Cronin, Orrock & Wallden {isn't there a 'how many NDs' light bulb joke in there somewhere; or a 'round up the usual suspects' reference?}], which states:

    “a number of well-conducted studies have also shown the benefit of HVLA [high velocity low amplitude] thrust in chiropractic practice in the treatment of conditions such as infantile colic and pyloric stenosis [{wow!} p.015...and one of my favorite lines in the chapter, naturopathy's nonsensical old saw that naturopathy's] principles are based on the objective observation of the nature of health and disease, and are continually re-examined in the light of scientific advances [p.002...principles such as, the treatment must] harmonize with the life force [p.011...per naturo.'s model of] a vitalistic organism [p.0113].” Fascinating.

    Let me hazard: once something science-ejected is labeled science, then of course a treatment without a justifiable amount of evidence to warrant its use is HUGELY efficacious!

    In Cloud Cuckoo Land: ND, DO [UK], or DC.

    There is a LONG list of references at the back of that chapter, including, my favorite:

    Beach, W. A treatise on anatomy, physiology, and health. Baker & Scribner, New York; 1848 [that's YEAR, not page number! Just to show what era of knowledge they're leaning on].

    “Continually re-examined in the light of” those kinds of scientific advances, ya know: the WRONG ones, before much was actually known…

    the ones now justifiably discarded.

    -r.c.

  16. niclucas says:

    Great post – enjoyed the critical appraisal. Also enjoyed the comments. I have a couple of things to add:

    To Blue Wode

    As far as comparing apples with apples, I must agree with the chiropractors about only comparing ‘chiropractic manipulation’ with ‘chiropractic manipulation’ – as I’m sure you would too. By analogy, there’s no point pretending that acetaminophen and ibuprofen are the same, when they’re not.

    In the Australian study you mention, only about 3% of the physiotherapists in that study used the technique which typically results in a ‘pop’ or ‘click’; instead they used what is also referred to as ‘mobilisation’, a gentle oscillation of the spine. Whereas the technique chiropractors typically use does result in such clicks an pops. So, to be fair, the Lateline story failed to identify this fact.

    Nevertheless, I think the importance of your argument is that the chiropractors can’t pick and choose when they use this argument. They can’t deny evidence that does not support them because it ‘wasn’t chiropractic’ and then turn around and site evidence in their favour, when it also ‘wasn’t chiropractic’.

    This links also to a comment by JMG who wrote about ‘violent physical manipulation’. The use of the word ‘violent’ is unfortunate, because JMG has no evidence about the violence of the techniques. How would one define ‘violent’?

    There is often a presumption that chiropractic is synonymous with manipulation – and this is a problem, because the word ‘manipulation’ lacks clear definition in the literature.

    So, it doesn’t help the situation to equate chiropractic (which means many things) with the word ‘manipulation’ (which is poorly defined) and associate these with the word ‘violent’. I think this just adds noise.

    The same applies to comments about “baby’s necks”. While I understand that pmoran is probably equating the ‘chiropratic’ treatment of children with ‘manipulating their necks’, I don’t think this is safe to assume.

    No doubt some chiropractors do use manipulation techniques in the cervical spine to produce ‘clicks’ in the baby’s necks – but not all do – and so this is again an example of thinking that chiropractic treatment is synonymous with manipulation – and indeed manipulation of the neck. It’s not.

    daijiyobu makes some great comments about CAM – and I don’t disagree. What I’d like to note, however, is that similar disingenuous cognitive biases also occur in so-called ‘orthodox’ medicine.

    In fact, I don’t particularly like the differentiation between ‘orthodox’ and ‘alternative’ or ‘complementary’ medicine. My preference is to view medicine as either having evidence of efficacy or not – irrespective of whether it is ‘orthodox’ or ‘CAM’.

    If a herb turns out to be efficacious in the treatment of acne and has benefits over usual care, then why is it ‘alternative’ or ‘naturopathic’? If it withstands the scrutiny of a well designed RCT, why shouldn’t it be ‘best practice’ to prescribe the herb? I think we can do without the unnecessary labels.

    My main research work is in pain medicine/physical medicine, and there are also examples of ‘orthodox’ treatments that don’t work, but that are still trotted out by those who profit from applying them (e.g. trigger point injections for ‘back pain’ coming from presumed muscle pain).

    Systematic reviews of dry needling and wet needling show that these are no better than placebo. In addition, systematic reviews also show that the entity itself – the trigger point – cannot be reliably identified by experts.

    Any professional association has an ulterior motive. A professional association exists for the benefits of it’s members. Ignoring the negative and promoting the ‘not-so-negative’ is to be expected from such a group – and we haven’t been let down in this regard.

  17. Dr*T says:

    I agree with MJRobbins – it’s a shame more linky love wasn’t given to the groundswell of UK skeptical bloggers who have kept pushing this story.

    Still, chiropractic in UK is definitely feeling the pain caused by the onslaught of complaints and articles by skeptics, even to the point where chiropractors (in response to specific complaints made about them) have been forced to admit on their website that:

    “Chiropractic has never cured anyone of anything.”

    T

  18. Why complain about linkylove when we’ve got the ability to post them ourselves in a reply?

    For instance: on the Anax Weblog (which is quite a gem!) they recently posted the article by ‘Ezard Ernst’ (What you should know about chiropractic), on which an American chiro replied. Well, perhaps I’m just a nursing student and I’m not down in the dirt doing research, but the unfolding of the thread was quite hilarious considering the science parts…

    http://anaximperator.wordpress.com/2009/06/11/what-you-should-know-about-chiropractic/

    Perhaps this doesn’t add to the general notion of rigorous scientific evidence on behalf or against chiro, but I’d say fight fire with fire. I have a great anecdote on definitive lack of knowledge about science. And it’s a Dr.(!) and a Bachelor of science(!) for crying out loud.

  19. Joe says:

    @ niclucas on 09 Jul 2009 at 9:59 am “If a herb turns out to be efficacious in the treatment of acne and has benefits over usual care, then why is it ‘alternative’ or ‘naturopathic’? If it withstands the scrutiny of a well designed RCT, why shouldn’t it be ‘best practice’ to prescribe the herb?”

    Sure, I suppose you can list the herbs that have passed those tests; they are few in number.

    @ niclucas on 09 Jul 2009 at 9:59 am “No doubt some chiropractors do use manipulation techniques in the cervical spine to produce ‘clicks’ in the baby’s necks – but not all do – and so this is again an example of thinking that chiropractic treatment is synonymous with manipulation – and indeed manipulation of the neck. It’s not.”

    We have to address the lowest common denominator which is the chiro who will visit violence on customers’ necks. Abstract http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B75KC-4F1H9GS-5&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=754fe88415cd702aa52be6484f7005b8 It seems 90% of chiros make the rest look bad.

  20. niclucas says:

    @ Joe. You sound almost disappointed that some herbs made it through? ;-) But I could be mistaken.

    The article you have referred me to about the opinions, attitudes and practices of chiropractors:

    1. Only surveyed North American chiropractors (I know, it would be ideal to be able to generalize that to all chiropractors in all geographic regions, but I’m not comfortable doing that in this case)

    2. The use of the term ‘adjustment’ is poorly defined in the literature and shouldn’t really be described as ‘violence’. An alternative critique of the word ‘adjustment’ is that it implies that something is actually ‘adjusted’, whereas there is no evidence that the bones change their spatial relationship to each other following said ‘adjustment’. I don’t like the term as it isn’t anchored in the basic science studies of joint manipulation.

    3. The response rate was surprisingly good, but still only just scrapped the 60% mark which doesn’t fill me with confidence. What about that other 40% who just didn’t respond? Might they have been systematically different in their opinions and practices? Who knows. Maybe, because they were research savvy, they thought the study was flawed and so didn’t bother with it. Maybe they were so far down the rabbit hole that they don’t value any scientific inquiry at all!?

    What did make me shake my head was the number of respondents who actually held the belief that ‘vertebral subluxations’ are the cause of 60% visceral complaints!

    We don’t need these results to be generalizable to chiropractors as a whole to be perplexed as to why these particular individuals hold this belief.

    The most damning thing of all – which no one is talking about – is the reliability and validity of the diagnostic procedures purported to identify the presumed vertebral subluxation that they subsequently assume causes visceral disease.

    The whole thing falls down right there – since there is negative evidence that chiropractors can reliably detect these things.

    As a corollary, however, physicians are injecting ‘trigger points’ with local anesthetic or botox despite the evidence that these cannot be reliably identified either.

    Cognitive bias, lack of attention to detail, assumptions, ignorance, profit, and outright fraud are problems that afflict both ‘orthodox’ and ‘alternative’ medicine, simply because both ‘types’ of professions contain humans.

    1. Gemmell H, Miller P. Interexaminer reliability of multidimensional examination regimens used for detecting spinal manipulable lesions: A systematic review. Clinical Chiropractic 2005; 8: 199-204
    doi:10.1016/j.clch.2005.09.002

    2. May S, Littlewook C, Bishop A. Reliability of procedures used in the physical examination of non-specific low back pain: A systematic review. Australian Journal of Physiotherapy 2006; 52: 91-102

    3. Najm WI, Seffinger MA, Mishra SI, Dickerson VM, Adams A, Reinsch S, Murphy LS, Goodman AF. Content validity of manual spinal palpatory exams – A systematic review. BMC Complement Altern Med 2003; 3: 1
    http://www.ncbi.nlm.nih.gov/pubmed/12734016?dopt=AbstractPlus&holding=f1000,f1000m,isrctn

    4. Seffinger MA, Najm WI, Mishra SI, Adams A, Dickerson VM, Murphy LS, Reinsch S. Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature. Spine 2004; 29: E413-25
    http://www.ncbi.nlm.nih.gov/pubmed/15454722?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

    5. Stochkendahl MJ, Christensen HW, Hartvigsen J, Vach W, Haas M, Hestbaek L, Adams A, Bronfort G. Manual examination of the spine: a systematic critical literature review of reproducibility. J Manipulative Physiol Ther 2006; 29: 475-85, 485 e1-10
    doi:10.1016/j.jmpt.2006.06.011

    6. van Trijffel E, Anderegg Q, Bossuyt PM, Lucas C. Inter-examiner reliability of passive assessment of intervertebral motion in the cervical and lumbar spine: a systematic review. Man Ther 2005; 10: 256-69
    doi:10.1016/j.math.2005.04.008

    7. Lucas N, Macaskill P, Irwig L, Moran R, Bogduk N. Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature. Clin J Pain. 2009 Jan;25(1):80-9.
    http://www.ncbi.nlm.nih.gov/pubmed/19158550?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedreviews&logdbfrom=pubmed

  21. Joe says:

    @niclucas on 09 Jul 2009 at 9:36 pm “… The most damning thing of all – which no one is talking about – is the reliability and validity of the diagnostic procedures purported to identify the presumed vertebral subluxation that they subsequently assume causes visceral disease.”

    The fact that chiros cannot diagnose is understood. It just isn’t quite relevant to this topic. At least one of the studies had subjects that had been medically diagnosed with asthma. Even if chiros could diagnose illness, their methods still do not treat illness.

    Thanks for the references.

  22. Scott says:

    Of course, when you have only one “treatment” and claim that everyone always needs it, why bother to diagnose? It’s not like anything would be different based on a diagnosis anyway.

  23. nwtk2007 says:

    scott – “Of course, when you have only one “treatment” and claim that everyone always needs it, why bother to diagnose? It’s not like anything would be different based on a diagnosis anyway.”

    That might be the most stupid comment I have ever heard by an anti-chiro. (Actually Joe’s comment about how we shouldn’t listen to our patients was the MOST stupid.) It indicates a total lack of knowledge about what chiropractors are doing these days, in real clinics working with real injuries and real musculoskeletal conditions.

    scott, your bias is showing.

  24. Joe says:

    Another challenge to the chiro’s “plethora of evidence” written by Dr. Ernst: http://www.bmj.com/cgi/content/extract/339/jul08_4/b2766

    But, wait- there is an anemic response by chiros http://www.bmj.com/cgi/content/extra…/jul08_4/b2782

    The BMJ articles are beyond a paywall and my university access is down for maintenance.

    A reply http://www.quackometer.net/blog/2009/07/what-next-for-british-chiropractic.html

  25. Joe says:

    @nwtk2007on 10 Jul 2009 at 11:17 am “… scott, your bias is showing.”

    Is bias a bad thing? I am biased (downright bigoted) against child abuse- are you ready to offer the positive side of child abuse?

    What we are looking for is evidence, that rises above you anecdotes.

  26. Scott says:

    Why don’t you provide some actual evidence if you claim it’s wrong?

    Believing what the evidence says is not bias, by the way. If sufficient evidence is presented that chiropractic actually has anything to it, or that most chiropractors DON’T claim effectively everyone who comes to see them has subluxations and needs manipulation forevermore, I’ll gladly change my mind.

  27. Joe says:

    @Scott on 10 Jul 2009 at 12:38 pm “Why don’t you provide some actual evidence if you claim it’s wrong?”

    You have it backwards- they have to prove they are right. That’s the rule- I don’t make the rules, I just adhere to them. The overwhelming evidence, inre chiro, is that they cannot prove their claims.

    @ Scott on 10 Jul 2009 at 12:38 pm “If sufficient evidence is presented that chiropractic actually has anything to it …”

    Go ahead, you can be the first person to demonstrate that “chiropractic has anything to it”(beyond low-back pain). (If you have compelling evidence favoring any chiro treatment, the procedure will be known as “medicine.”)

    Chiros often accept that challenge, and then become “too busy” to respond.

    @ Scott on 10 Jul 2009 at 12:38 pm “…. most chiropractors DON’T claim effectively everyone who comes to see them has subluxations and needs manipulation forevermore …”

    The data goes against you: “How chiropractors think and practice” William P. McDonald et al “Seminars in Integrative Medicine” 2004 V.2 #3 92-98 . According to that survey of, and by, chiros 90% believe in subluxations and 60% believe subluxes are important in visceral disease.

    However, I await your data. I am especially interested in your data concerning the number of chiros that recruit “maintenance” manipulation (forevermore).

  28. tgobbi says:

    # nwtk2007on 10 Jul 2009 at 11:17 am
    scott – “Of course, when you have only one “treatment” and claim that everyone always needs it, why bother to diagnose? It’s not like anything would be different based on a diagnosis anyway.”


    That might be the most stupid comment I have ever heard by an anti-chiro. (Actually Joe’s comment about how we shouldn’t listen to our patients was the MOST stupid.) It indicates a total lack of knowledge about what chiropractors are doing these days, in real clinics working with real injuries and real musculoskeletal conditions.

    ***

    My immediate response to the above is to agree with both Scott and nwtk. (Reminds me of a great line in “Fiddler on the Roof:” two villagers are arguing and Tevye agrees with both of them. Another villager says to Tevye: “He’s right and he’s right? How can they both be right?” To which Tevye responds: “You know, you’re also right!”

    On second thought, though, I only agree with nwtk to a certain extent. Agreed that SOME chiropractic treatment may be efficacious for SOME patients SOME of the time. But this is a very narrow “some of the time.” It refers to simple musculoskeletal conditions.

    The problem, as we all know, is when DCs (most of them) think they can be all things to all people: primary care physicians; pediatricians; nutritionists; psychologists; etc. They are neither trained nor qualified to be any of these – unless, of course, one deems chiropractic teachings on nutrition to be efficacious, a risable contention. Further complicating the situation is the prevalent anti-vax orientation within chiropractic, plus the anti-medical/pharmaceutical bias that is rife therein.

    tgobbi

  29. Joe says:

    The BMJ articles I cited, above, are now in my possession. The vice president of the BCA has trimmed the bogus list of references in support of chiro to just 19 (as opposed to 29); but he still found it necessary to pad the list with irrelevant articles (seven of them if you count the three on bedwetting which was not a claim challenged by Singh). None of the pertinent articles provides high-quality evidence in favor of chiro. Of course, they still omit the strongly negative articles. Such omission must count as fraud.

    The BCA VP continues to snivel that they never wanted Singh to insist on defending himself at trial. As law-blogger Jack of Kent has observed- when one files a lawsuit, a trial is a normal, anticipated outcome.

  30. OZDigger says:

    Are any of you “scientists” (sic!) brave enough to comments of Dr. Marcia Angell, former editor in chief on the New England Journal of Medicine.

    She said recently that the pharmaceutical industry is now just a “marketing machine to sell drugs of a dubious benefit”.

    She resigned her position as editor over an attempt to use the journals name to brand and market other less proven sources of health care information.

    Would all you “scientists” tell me what drugs she was referring too? Is this an isolated instance or are there other examples?
    How about some examples?

  31. Joe says:

    @OZDigger on 11 Jul 2009 at 4:21 pm “… Would all you “scientists” tell me what drugs she was referring too?”

    Since you raised this irrelevant topic, I suppose you can tell us.

  32. OZDigger says:

    Not really irrelevant Joe, just an example of how inconsistent you are with your arguments. Always very willing to cherry-pick things to suit yourself.

  33. Joe says:

    @OZDigger on 11 Jul 2009 at 5:51 pm

    I take it that you cannot tell us the drugs to which she referred.

    Not that it is relevant to the BCA’s bogus list of “evidence.” Do you know what “irrelevant” means? You use that word .. I don’t think you know what it means …

  34. OZDigger says:

    I have obviously hit a sore point with you Joe, hit a soft nerve, I think.
    Ah well, we know where your Achilles heal is.

  35. pmoran says:

    “She said recently that the pharmaceutical industry is now just a “marketing machine to sell drugs of a dubious benefit”. ”

    A half-truth. It applies mainly to the enormous investment of drug companies in the development and marketing of “me-too” drugs. They are marketed as having advantages over older drugs, but they exist mainly to capture a slice of lucrative markets. Doctors are induced to try them by the promise of fewer side effects or other marginal benefits. These may or may not materialize in practice or with further research,

    All this was inevitable, to some extent, at this stage of medicine’s evolution. Truly major medical breakthroughs are further apart now. Medicine now strains for small, incremental gains in the treatment of and prevention of common but difficult medical problems such as heart disease, psychological distress, arthritis, and osteoporosis and other problems of aging.

    Physicians, drug companies and device manufacturers are thus being driven (by differing motives) to explore pharmaceutical and even surgical treatments that may have such marginal gains in cost/risk/benefit terms as to be approaching the limits of detection by scientific studies of any practical size and expense.

    I think this is part of the reason why large, apparently well-performed studies can produce conflicting results — and how swings of a mere 2-3 per cent in desirable versus undesirable outcomes can mean that doctors have to revise opinion about once well-accepted treatments.

    Such happenings feed the perception that there is something fishy going on. Sometimes that is true, but less rampantly, less culpably and less threateningly for public health, than some like to think.

  36. OZDigger

    Are any of you “scientists” (sic!) brave enough to comments of Dr. Marcia Angell, former editor in chief on the New England Journal of Medicine.

    She said recently that the pharmaceutical industry is now just a “marketing machine to sell drugs of a dubious benefit”.

    She resigned her position as editor over an attempt to use the journals name to brand and market other less proven sources of health care information.

    Would all you “scientists” tell me what drugs she was referring too? Is this an isolated instance or are there other examples?
    How about some examples?

    I would assume (as pmoran) did that she is referring to the slew of me-too drugs.

    However, I am confused how this is relevant to the efficacy of chiropractic.

    Not really irrelevant Joe, just an example of how inconsistent you are with your arguments. Always very willing to cherry-pick things to suit yourself

    Cherry-pick: You use that phrase, but I don’t think it means what you think it means.

    We are commenting on a post about chiropractic. Joe is discussing chiropractic. You then start discussing pharma. I’m confused how Joe’s NOT having discussed pharma is cherry picking.

    Indeed, your bringing pharma into this is, at best irrelevant, and at worst, tu quoque fallacy.

    I’m noticing a trend where OZDigger and nwtk2007 always push hard right away to defend chiropractic, and then act as if conventional medicine is bad.

    Yet when their fallacious arguments are swept away and their “questions” are answered, they never respond, ignore the responses they ask for, and then move on as if nothing happened.

  37. Joe says:

    Here is a recent review of pediatric chiro

    Allan Gotlib and Ron Rupert “Chiropractic manipulation in pediatric health conditions – an updated systematic review”
    Chiropractic & Osteopathy 2008, 16:11 doi:10.1186/1746-1340-16-11
    This article is available from: http://www.chiroandosteo.com/content/16/1/11

    “Summary: There has been no substantive shift in this body of knowledge during the past 3 1/2 years. The health claims made by chiropractors with respect to the application of manipulation as a health care intervention for pediatric health conditions continue to be supported by only low levels of scientific evidence. Chiropractors continue to treat a wide variety of pediatric health conditions. The evidence rests primarily with clinical experience, descriptive case studies and very few observational and experimental studies. The health interests of pediatric patients would be advanced if more rigorous scientific inquiry was undertaken to examine the value of manipulative therapy in the treatment of pediatric conditions.”

  38. Blue Wode says:

    With Simon Singh is visiting Adelaide and Sydney in Australia at the moment, it’s worth bearing in mind that back in October 2008 the Australian Medical Association warned against child chiropractic care:

    Quote
    “Parents are wasting money on unnecessary chiropractic care for young children which is not achieving any medical result, says the Australian Medical Association (AMA). Early chiropractic treatment for children under 10 is “quite inappropriate”, says AMA state president Peter Ford, because there is no medical evidence to suggest it works. Dr Ford urged parents concerned about their child’s spine to consult a doctor or pediatrician and, if necessary, a specialist.”

    More…
    http://www.news.com.au/adelaidenow/story/0,22606,24508558-2682,00.html

    And a few months before that, the Chiropractors’ Registration Board of Victoria, Australia, proposed new chiropractic standards “that attacked core beliefs and practices of subluxation-based chiropractic”:

    Quote
    “ The draft document, which is intended to apply to children up to the age of about 13, states that “Non-indicated, unreliable and invalid diagnostic tools, instruments or methods and unnecessary diagnostic imaging procedures are to be avoided.” It specifies: (1) Routine radiographic examination and re-examination of pediatric patients is not recommended without clear clinical justification. X-ray examinations should not be performed solely for the detection of biomechanical disorders of the spine, such as vertebral subluxations, postural analysis or for the monitoring of spinal curves or posture, unless for monitoring progressive scoliosis; (2) The use of . . . surface electromyography (SEMG) or thermography, is not considered appropriate in the diagnosis of childhood conditions; (3) There is currently an overwhelming lack of good quality scientific evidence to support the use of spinal manipulation in the treatment of most “Type O” conditions. “Type O” stands for organic/visceral disorders (diseases) as opposed to “type M” (musculoskeletal/biomechanical disorders). SEMG and thermography have no legitimate diagnostic value, but many subluxation-based chiropractors use them to sell patients long courses of unnecessary treatment.”

    http://www.ncahf.org/digest09/09-05.html

  39. nobs says:

    Joe->>”….application of manipulation as a health care intervention for pediatric health conditions continue to be supported by only low levels of scientific evidence. Chiropractors continue to treat a wide variety of pediatric health conditions. The evidence rests primarily with clinical experience, “<<

    Sounds eerily akin to the claims justifying off-label prescribing. SO…one must logically conclude you do not advocate the practice of off-label prescribing….correct?

  40. Joe says:

    @nobs on 12 Jul 2009 at 4:05 pm

    No. Chiroquacks notions do not compare to “off-label” prescribing. Chiros engage in bogus “diagnosis”and “treatment.” It is pathetic that you try to equate off-label-prescribing to baldfaced ignorance.

  41. Blue Wode says:

    The full text of the science and libel articles in the latest issue of the British Medical Journal (BMJ) which addressed the BCA/Singh affair can be found here:
    http://musicweaver.users.btopenworld.com/BMJ_Keep-libel-laws-out-of-science-articles.htm

    They include the pieces by Fiona Godlee (BMJ Editor), Richard Brown (Vice-President of the BCA), and Professor Edzard Ernst.

  42. Joe says:

    In the body of the post “The BCA also neglected to reference a review of the evidence for chiropractic for colic by Hughes and Bolton (2) which concludes:

    “The evidence suggests that chiropractic has no benefit over placebo in the treatment of infantile colic. However, there is good evidence that taking a colicky infant to a chiropractor will result in fewer reported hours of colic by the parents.”

    Their conclusion was curious – chiropractic treatment for colic does not work but parents report that it does. Ordinarily science-based practitioners would simply interpret such results as being consistent with a placebo effect alone.”

    The fewer reported hours may be simply the result of keeping a diary for the study, rather than an actual reduction. Klougart N, Nilsson N, Jacobsen J. Infantile colic treated by chiropractors: a prospective study of 316 cases. J Manipulative Physiol Ther 1989;12:281-8.

    One of the authors (Bolton) of that ‘curious conclusion’ is Director of Research Anglo-European College of Chiropractic. It is common for proponents to see the “glass half full” when examining data that is considered inadequate by dispassionate observers. A few years ago (and I cannot find it right now) I got the impression that the Cochrane Reviews were contaminated by the presence of naturopaths.

    The BMJ has made all the discussion of BCA v Singh open to the public http://www.bmj.com/cgi/content/full/339/jul08_4/b2766

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