The Duck, The Flowering Tautology, The Leicester Prince and the value of being Ernst

February 22, 2011
By

I have invited a number of people but one professor in particular to answer me this: how can anyone deduce comment regarding efficacy of treatment if none of the studies they refer to differentiate causation? (he said he couldn’t make his point in 140 twitter characters)

My point is: It’s a bit like saying that an antibiotic which kills off a certain strain of bacteria which causes chest infections doesn’t work because it doesn’t cure all chest infections…

It strikes me as utterly ridiculous and odd… It strikes me as obvious that the bravado some people employ to “crack down on quackery” (good on you) is in the case of chiropractic care misguided, founded on quicksand and symptomatic of an unhealthy obsession with pointing out other people’s weaknesses. What I mean is this: when we look at the available research evaluating the efficacy of say spinal manipulation (which a lot of these self-professed quackbusters equate to “chiropractic”),… well, those studies compare the outcome measures of treating a generic non-specific back pain suffering patient with “a” manipulative treatment protocol, compare the outcomes to doing nothing, compared with doing exercise, compared to combining manipulation to exercise etc… Now stop and think about this…. what percentage of non-specific back pain is CAUSED by manipulable leasions? What percentage of non-specific back pain cases is CAUSED by a lack of exercise? And now we’re at it,… what percentage of such back pain cases is CAUSED or AGGRAVATED  (please note the distinction the author makes between causal and co-factorial relationships) by anatomical leg length discrepancy/descending malocclusion/obesity/stress-coping strategies to name but a few? Now consider a 100 generic “non-specific back pain sufferers” (I picked 100 just to keep the numbers simple but if you’d like you can think of 100.000 or even 362 if you want it awkward). Of those 100 some will be in the state they’re in because of spinal dysfunction some because of stress, some because of obesity. Manipulating the latter two is in my opinion a nonsense so we’re left with 70 (no factual basis to this figure and no animals were hurt in the writing of this blog) the other 30 are sent out to learn coping strategies and loose weight. The 70 that are left: 35 of them have gait issues to some extent. Some (say 20) have gait issues which cause the spinal dysfunction some have gait issues which aggravate the spinal dysfunction. The 20 are sent to a good podiatrist (please note “good”-this is a salient point) or given an off the shelf solution where possible the other 15 are given the same but concurrently need to have the other co-factors identified and go back in the pool of the 35 remaining non-gait based spinally dysfunctional back pain patients. So those 50 (100 minus the 30 non-spinal dysfunction patients = 70 and 70 minus the 20 referred out to podiatry=50) are then assessed for descending malocclusion problems. 10 of those will have dysfunctional movement patterns (spinal dysfunction) caused or aggravated by descending malocclusion patterns. Of those 10 there are 3 whose problems are entirely caused by this, the other 7 are aggravated. The 3 are referred outo a good splint therapist (again salient point) and the 7 the same but they come back into the pool leaving us with 47 of the 100 whose aggravating factors have been dealt with and 53 whose causal factors have been treated via referral pathways. Those 47, and only those 47 are approriate candidates for the assessment of efficacy of spinal manipulative therapy.

Here comes the joke: even if you manipulate the 100, indiscriminately of other causal and aggravating factors, EVEN THEN does spinal manipulative therapy come out looking like it’s efficacious!!!

There is only one conclusion that can be seriously drawn from the research and that is that spinal manipulative care is an extremely powerful and efficacious technology to address non-specific back pain… but then we already knew that, as chiropractors, osteopaths, osteomyologists and physiotherapists. How efficacious? I don’t know because I made the numbers in the example up, but one thing is for sure; it stands to reason that it is EVEN MORE EFFICACIOUS THEN WHAT THE RESEARCH SAYS.

So that’s the quicksand. It’s quicksand because these so-called sceptics (they are nothing of the sort) use the research argument to point at efficacy or lack thereof. I have always stood by the argument that there is no research available which would allow anyone to draw conclusions about the efficacy of spinal manipulative care, let alone chiropractic care. That’s of course not a good thing, but it is what it is and it certainly does not allow for these muppets to draw the conclusions they are drawing.

But! and this is where some introspection is fair point to balance the argument: chiropractors have been muppets for making claims they couldn’t make (as there is no good quality evidence “for” either), chiropractors have been muppets for being tacky, unprofessional and unrepresentative and have in consequence created ammunition for the other set of muppets to scoop up, embellish and throw at us. So,… and this is where some appreciation of the intricacies of the human mind comes in handy: can I blame these sceptics for being so dim-witted? No, not really, firstly most of them have no idea of what clinical life is like, have no or very limited understanding of anatomy, physiology, pathology etc. and are wrapped up in the world of stata or html code (or both). It’s a version of reality they are comfortable with and they are doing what we all do when we are comfortable, … become complacent and believe our own male bovine excrement.But that said, I am grateful to them (in a philosophical humanist kindaway) for putting the profession in disarray and maybe this will mean we are going to clean this gig up. I will do my best, I hope you will do too.

As they say on twitter: #epicfail

Kind regards,

Stefaan Vossen

This is only the beginning

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  • Fedup

    Have you seen the figures before and after “adjusted” at 10 weeks?

  • Fedup

    thank you colin. I will have a look at. though when questioned about prior beleifs of cst 74% were not strong and then they class the result as an “interesting reflection?” after that “significant differences were found on some subscales of quality of life of the children and carers and sleep at 10 weeks” but not really counted because only 61% of paticipants were questioned. why? significant difference!! 55% from intervention group. 55% of 61%? Only had a quick look. thanks again

  • drchappy

    Excellent article. I could not agree anymore.

  • Liamchiro

    Not everybody on Pulse is as blinkered or bias as EE. Check this out.
    http://www.pulsetoday.co.uk/story.asp?sectioncode=20&storycode=4126867&c=2

  • http://twitter.com/welshandgrumpy Colin Jenkins

    http://www.ncbi.nlm.nih.gov/pubmed?term=ISRCTN45840554

    I don’t see anything about “GCAS”?

    Global health was not for the parents – it was for the children. It’s very clear in the paper itself.

  • Fedup

    Pub med and it’s talking about the global health score given to the parents.

  • http://twitter.com/welshandgrumpy Colin Jenkins

    Quality of life was measured using CHQ and was the same between groups. I think you are confusing CHQ with “global health”. Email me your snail mail address and I’ll send you my copy of the paper. colin@sailwave.com.

    PS: where did you get that abstract snippet from? – it’s not what’s in the paper!

  • Fedup

    Hi colin I have been following this on pulse, the problem is the parents haven,t just come up with anectodal observations they have used a global health scale provided by the researchers. I just can,t see why or how this can be ignored.

    “Compared with children in the control group, carers of children receiving cranial osteopathy were nearly twice as likely to report that their child’s global health had ‘improved’ at 6 months rather than ‘decreased’ or ‘remained the same’ (38% vs 18%; odds ratio 2.8, 95% CI 1.1 to 6.9).”

    “Abstract

    We evaluated the Children’s Global Assessment Scale (CGAS), an adaptation of the Global Assessment Scale for adults. Our findings indicate that the CGAS can be a useful measure of overall severity of disturbance. It was found to be reliable between raters and across time. Moreover, it demonstrated both discriminant and concurrent validity. Given these favorable psychometric properties and its relative simplicity, the CGAS is recommended to both clinicians and researchers as a complement to syndrome-specific scales.”

    I don’t see why it was included in the study if it’s results are going to be dismissed. Please answer that question especially when it seems the CGAS results are classed as valid.”

    A valid point?

    This was the original title of the study “Osteopathy for children with Cerebral Palsy: a randomised controlled trial of the effects of osteopathy on the health and well being of children with cerebral palsy”

    see here http://www.controlled-trials.com/ISRCTN45840554/45840554

    Study hypothosis. In children aged 5 – 12 years of age with a diagnosis of cerebral palsy does osteopathy, compared to treatment as usual, produce improved motor function, improved quality of life, improved sleep or a reduction in fits?

    does the improved CGAS score not mean the carer feels the quality of life or health and well being of their child has improved? This is part of what the study was designed to evaluate and now

  • http://twitter.com/welshandgrumpy Colin Jenkins

    I printed it – I didn’t keep an electronic copy. As the authors note, the feelings of the parents/carers is interesting but hardly unexpected given that they were not masked to treatment groups and obviously want their kids to get better. As parents making observations about our children the bias is going to be huge. c.f. parents of children ‘remembering’ that signs of autism appeared just after vax (which will happen – it’s a mathematical certainty) but not at the anecdotal frequency – then in court the actaul facts come out and the parents are simply misremembering (truthfully) because it will benefit their children and maybe lesson guilt; massive bias. Surely knowing this (people have written books about it) we should be judging the outcome based on the most objective, minimally subjective, minimally biased result – especially as in this case it seems to be commonly accepted to be a good test.

    Which is not to say the study is not flawed (error analysis? and substitude test at start) – just that you*are* cherry picking; you are, as usual, ignoring the rational and indulging in the ideological, as it the want of CAM clinicians worldwide.

    I think our minds just work differently! I ;love this blog and think Richard posts some awesome revelations but I have never succeeded in following his logic (or any other trad chiros – slight generalisation) when we come to debate something – like vax on twitter recently :) The fagility of annecdote is well known but you (trad chiros and CAM clinicians in general) constantly cling to it. It makes no sense to me.

  • Fedup

    £133 a year? or £24 for single article. You have it?

  • http://twitter.com/welshandgrumpy Colin Jenkins

    Have you read the whole paper? (the CP one). The authors explain all. The secondary finding is pretty much irrelevant.

  • Fedup

    News flash EE only reads (and expects you) to only read the conclusion on any research. Obviously no bias or altering or missing data would ever been done. The authors conclusion is final!

    http://www.pulsetoday.co.uk/story.asp?storycode=4128779

  • Fedup

    EE calls this useless research.

    http://www.ncbi.nlm.nih.gov/pubmed/21395431

    Conclusions: The findings confirm other studies of patient satisfaction and physician characteristics. The availability of time, a holistic approach, and high physician empathy lead to high patient satisfaction. Homeopathic physicians probably are more likely to exhibit these characteristics. Practice implications: Health care policy should create conditions that enable individual physicians to be “good doctors.” For medical education, a stronger emphasis on interpersonal skills and practitioner empathy could lead to higher patient satisfaction and potentially better treatment outcomes. Homeopathy might provide a good role model for this type of education.

    Read that again EE “higher patient satisfaction and potentially better treatment outcomes”

  • http://www.chiropracticlive.com Richard Lanigan

    I made your point on Twitter and was accused of “cherry picking”! Having now read the study I think it is very relevant to a study of this sort. Skeptics tend to take a very narrow interpretation of evidence.

  • Fedup

    Found this regarding that study.
    http://www.controlled-trials.com/ISRCTN45840554/45840554

    It doesn’t mention CST just osteopathy.

    This was it’s title.

    “Osteopathy for children with Cerebral Palsy: a randomised controlled trial of the effects of osteopathy on the health and well being of children with cerebral palsy ”

    and this was the hypothosis

    “In children aged 5 – 12 years of age with a diagnosis of cerebral palsy does osteopathy, compared to treatment as usual, produce improved motor function, improved quality of life, improved sleep or a reduction in fits? ”

    So I would say that 38% of those who had osteopathy have seen the effects on the health and well being and improved quality of life.

    Fancy a change of title or a cherry anybody?

  • http://www.chiropractorswarwick.co.uk Stefaan A.L.P. Vossen

    and the editor is not publishing my further replies!? I was very courteous in them but got the impression from EE’s tweets that he has been asked to help with the sensorship…

  • Fedup

    http://adc.bmj.com/content/early/2011/02/23/adc.2010.199877.abstract?sid=eaa9d7e8-3337-48a4-90ba-5330368f1107

    Here is the study richard.

    “Compared with children in the control group, carers of children receiving cranial osteopathy were nearly twice as likely to report that their child’s global health had ‘improved’ at 6 months rather than ‘decreased’ or ‘remained the same’ (38% vs 18%; odds ratio 2.8, 95% CI 1.1 to 6.9).”

    I dont see how the conclusion can not include this as they have stated

    “Primary outcome measures Blind assessment of motor function by physiotherapists using the Gross Motor Function Measure-66 (GMFM-66) and quality of life using the Child Health Questionnaire (CHQ) PF50 at 6 months.

    Secondary outcome measures Parents’ assessment of global health and sleep at 6 months, pain and sleep diaries at 10 weeks and 6 months, CHQ PF50 at 10 weeks and quality of life of main carer (Short Form 36) at 10 weeks and 6 months. ”

    A part of their secondary outcomes has shown a very sgnificant improvement, why was this not included?

  • Fedup

    OMG EE is asking his faithfull underlings on twitter to comment on his blog as he is not really winning the argument. lol

  • Fedup

    Yet again EE is cherry picking his outcomes this on Pulse.

    “It was therefore courageous of colleagues at my medical school to test CST in a rigorous, pragmatic RCT (I or my team were in no way involved in this study). They recruited 142 children with cerebral palsy and treated them either with CST for six months or, in an attempt to allow for non-specific effects, gave them some attention control. At the end of the treatment period, none of the outcome measures (e.g. motor function, quality of life, sleep, pain) was significantly affected. In other words, CST does not work – at least not for cerebral palsy.”

    CST does not work was his conclusion. But If you have a look at the study, EE, as usual, left out part of their findings.

    “Compared with children in the control group, carers of children receiving cranial osteopathy were nearly twice as likely to report that their child’s global health had ‘improved’ at 6 months rather than ‘decreased’ or ‘remained the same’ (38% vs 18%; odds ratio 2.8, 95% CI 1.1 to 6.9).”

    38% compared to 18% reported an increase in global health following CST. Funny how he NEVER can comment on any positive. It just shows his bias, dripping in it actually.

  • http://www.chiropracticlive.com Richard Lanigan

    If that is true she loves him very much

  • Fedup

    Just think if it IS Ernst!! or his wife!! I once saw a twitter from a skeptic that referred to blue wode as she.

  • http://www.chiropracticlive.com Richard Lanigan

    I would love to meet Blue Wode, he is a fascinating character he knows about every wart on the professions bum and wont have a bad word said about Edzard.

  • http://www.chiropractorswarwick.co.uk Stefaan A.L.P. Vossen

    To be fair the one who did describe it as such is not really a sceptic now is he? lol

  • http://www.chiropracticlive.com Richard Lanigan

    Another good article by Stephen Pearl on Edzard Ernst http://www.acatoday.org/content_css.cfm?CID=4317 Skeptics describe this article as an “attack”

  • http://www.chiropractorswarwick.co.uk Stefaan A.L.P. Vossen

    Thanks, hope it all makes sense and taht it encourages a rethink of what its all about….
    Regards to all chiropractors, osteopaths etc reading these posts. I think it is crucial a good rethink happens sooner rather than later.
    Stefaan

  • http://www.chiropracticlive.com Richard Lanigan

    I found the interview particularly revealing and would urge all chiropractors to listen to it. It takes about 45 minutes. Blue Wode claims it is “heavily edited” my understanding is that the cometary by the chiropractor who did the interview was removed to let people figure out for themselves whether Ernst can claim to be an authority on chiropractic or the profession. Please post a comment because I suspect this interview is going to receive much attention in the coming months.

    Blue Wode feels our attacks are unfair to the good professor so in the name of balance I will put a link to this posting by Skepticat in defence of Edzard Ernst.

    “Skepticat” is particularly venomousness skeptic, a humanist who lives by the “golden rule”, she refused to let me foillow her on twitter because I am “bonkers” which may endear her to many in the chiropractic profession Part 1 http://www.skepticat.org/2010/03/the-importance-of-being-ernst/ Part 2http://www.skepticat.org/2010/03/the-importance-of-being-ernst-2/ these are the same links Fed up did about an hour ago sorry I did not see it. We are getting like the skeptics, keep posting stuff so eventually it has some sort credibility

  • http://www.chiropracticlive.com Richard Lanigan

    Great post Stefaan, however you may be accused now of being anti scientific. The blind are leading the blind and none of them realise why they cant see. I think the next few weeks are going to be interesting, the GCC has to complete their “investigation”, chiropractors will have to decide where their future lies and whether they want to be regualted by public opinion and commom law or the GCC.

  • Fedup

    http://ontheotherhand.podbean.com/2011/01/19/ep-16-edzard-ernst-cam-critic-on-chiropractic-and-bias/

    Good blog post about ernst. Check out the podcast interview of the so called professor.

  • http://www.chiropractorswarwick.co.uk Stefaan A.L.P. Vossen

    The fox and the duck

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