Below in red is Andy Lewis response to my questions in the discussion we were having In an earlier topic. Andy raises a number of valid points which the chiropractic profession has struggled with in recent years (clear identity, definition of what chiropractors do, subluxation, wellness, etc etc. There are four associations in the UK representing just over 2000 chiropractors all with their own definitions). The infighting and a failure to develop a consensus view of chiropractic which the ACC paradigm hoped to achieve, but was rejected by the BCA and gradually was shelved, was as close as the profession has ever been to unity, that opportunity has long passed now the BCA is seeking prescribing rights. As the WFC agreed for years ago not using drugs and being experts in spinal function is the chiropractic brand the profession should rally around.
Andy has his view and I have mine, Andy believes I am trying to ape some sort of medical intervention and attempting “medical diagnosis”. That is a requirement of the GCC that chiropractors must put a medical diagnosis in their notes. Thats what medical people are trained to do, chiropractors are trained to locate dysfunction in spinal joints and they profession can not even agree on a name for this dysfunction( 300 at last count). So they start dabbling in medicine. In that respect I think common sense would tell the chiropractic profession they should concentrate on achieving consensus and understanding around the spine.
As for me seeing myself as the “only true chiropractor”. If I come across like that I apologise to chiropractors as that is not my intention. In fact my discomfort with people promoting that type of evangelical perspective was part of the reason I decided to stop working with Tedd Koren. The chiropractic profession, just like the Iraqi people have to decide their future themselves, it should not be imposed by people motivated by self interest and money. If I seriously thought I was the only true chiropractor, I would have gone into teaching or definitely started charging chiropractors to see and hear “the one true God of chiropractic” , believe me there are many of those in the chiropractic profession, I may be a lot of things, but thinking my way is the only way to practise is not one of them and why we have osteopaths, acupuncturists, and back rubbers working in our practices.
If I had all the answers I would be shouting them from the rooftops. The primary function of this blog was to highlight one fact, that the GCC was not fit for purpose and make clear I would not imply that I was a chiropractor in the UK. In performing this function, the blog has exposed unpleasant aspects of the chiropractic profession, but to tar the entire profession on the behaviour of those at the margins is unfair or for that matter stereotype all chiropractors is an inaccurate picture
I am standing up for what I do, not for all the different brands of chiropractic out there, unfortunately most chiropractors are keeping their heads down after BCA people in glass houses threw rocks and were surprised when the bully boy tactics did not work and people hurled the rocks back. I have been fighting these peoples efforts to silence dissenters since I was a student in the early 90s so I was not going to change my mind about that principle because I did not agree with what Simon Sing had to say.
Because sceptics are not satisfied with the evidence for what I do is hardly a reason for me to pack in. If what I do is “entertaining” and it helps people get through the day, great should they be denied the right to purchase that service because a minority dont approve of the practice? I have a client with Parkinsons who was in a wheelchair three months ago, he no longer uses the wheelchair and the quality of his life has been transformed, is it the adjustments, the swimming, the jokes, all I care about is that he is happy, I may even write up this case study, if this progress continues for another 6 months. I teach a “Retrocise” class at Esporta, no evidence for that should I stop, people enjoy the class is it the great music from the 60s or the exercise, who cares, they enjoy the class. I have never lived my life by others standards and while I love a good argument, my kids are the only people I care what they think.
In the early eighties I was working with the cream of Denmarks athletic talent. Getting them changing their diet, doing weight training and stretching etc, based on empirical evidence I collected travelling in the former Soviet Union and East Germany. What I was doing was well documented in Denmark but I never published anything in a peer reviewed journal. Physiologists from the August Krog institute did take an interest and gradually a consensus was established and now these approaches to training are the norm. 1986 Liverpool had just won the double, I spent two hours trying to convince their manager Kenny Dalglish to change their approach to preparing footballers. He was not interested, they had won the double, injured players he sent to the FA’s centre at Lilleshall and the team trained by mostly playing five a side games every day. Gradually more and more football managers have come round to a new way of thinking, however it was not “scientific evidence” that convinced them to change their ways, it was results.
Andy we will have to agree to disagree on chiropractic, I can not provide you with the level of scientific evidence you require, nor have I tried to pretend it is there, however as my example shows, absence of evidence is not evidence of absence. Thanks for your response below:
Richard, this is my response to your long rebuttal of my request for you to find some evidence that two chiropractors can reliably come up with the same diagnosis. I have been accused of cherry picking my evidence. I refute that. I have asked for you and other commenter’s to produce better studies than the ones I presented that I could have ignored. You have not done that. Instead, I get this… So, my answers…
RL: “Andy Andy the chiropractic adjustment is a skill which an untrained person would not be able to do, (Point 1)”
AL: I am sure. But a skill in itself does not mean the skill is medically useful. I am sure there have been many skilled bloodletters in the past.
RL: “as such some people do it better than others (point 2)”
AL: Indeed. But as a supposedly established medical profession one would have thought there would be agreed minimum standards in diagnosis and treatment. Is incompetence commonplace and acceptable in the chiropractic world?
RL: “A surgeon using a scalpel is a skill and as the Bristol enquiry showed us some surgeons do it better than others. Your study would seem to suggest that some chiropractors with time on their hands to compare their palpatory skills are not that good at it. (point 3)”
Firstly, I am not sure you feel the need to denigrate those that took part in these studies by saying they must have ‘had time on their hands’. A research ethic is a good thing, not something to be scoffed at. Secondly, it is your post hoc assumption that the tests of intra examiner reliability failed simply because the chiropractors were not very good. There is no evidence for that. I discussed reviews of multiple trials (Hestbaek and Leboeuf-Yde, (2001), Gemmell and Miller (2005)). It would be extraordinary that all trials just happened to pick incompetent practitioners. Of course, it is not possible to prove otherwise, but it would strike me as negligent to dismiss the results of these studies with a glib wave of your hand.
RL: “Many of these chiropractors whose skills are not very good wish to start prescribing medicines to their patients. You wish to make the case that their incompetence reflects on what I and other chiropractors do, I don’t accept that (point 5)”
AL: Note sure what happened to point 4. How do you know that the group that failed these intra examiner reliability tests are the same as those that now campaign for prescribing rights? Richard, from your writings, you do appear to wish to wear the mantle of the One True Chiropractor (even though it would be illegal to call yourself as such) but it would appear that the onus is on you and other chiropractors to show that these results cannot be generalised. Despite my repeated attempts to ask if you know of better papers than the ones I cited, all I get back is bluster. It would appear that the best evidence to date would suggest that chiropractors cannot diagnose with any repeatability. This is perfectly compatible with the hypothesis that chiropractic subluxation (or whatever you want to call it) is a myth. It would also strongly suggest that all you get through a chiropractic consultation is a theatrical placebo therapy.
RL: To prove that I have asked you the scientist to come up with a challenge to test my skills at finding “Subluxations” (point 6)
AL: I am just quite not sure what to make of your challenge and even if I should take you seriously.
Your challenge to me looks like one massive aunt sally. My $100 homeopathy challenge is just that – a challenge to homeopaths. You unilaterally decide that it also applies to chiropractors and then say that I am ‘retreating’ from it when I don’t jump at your proposal. You clearly have not read my homeopathy challenge as you say “Fuck the evidence Andy, I just want your $100”. The $100 is not a prize to be won, but the expected cost I anticipate homeopaths will require. (I note Delete Comment
(I note your attitude to evidence too). It is quite a specific challenge and I make no apologies that it does not extend to demonstrations of skill in chiropractic, tennis or beer mat flipping.
You appear to think this test does apply to you because you say I said that you were “indistinguishable from homeopaths”. You are in that, you are unable to evidence the basic assertions of your medical claims, are unable to provide good quality clinical evidence and bluster and obfuscate when challenged about this.
RL: To prove that I have asked you the scientist to come up with a challenge to test my skills at finding “Subluxations” (point 6)
AL: One thing my homeopathy challenge was for was to see if homeopaths could themselves think through what it would take to properly prove their assertions. They are pretty clueless and, your mountebanking looks as equally unsophisticated. Chiropractic is your claim, you should be in a position to supply good evidence and suggest your own tests.
RL: and to see if an adjustment can have an affect on blood supply to the brain (point 7) You have called us “benign fools” but so far you have not come up with a challenge to test my skills (point 8)
Here we get into some really insightful stuff. I have no doubt that a chiropractic session can have physiological effects. A test to see if such a back rub could result in measureable effects is not in question. The question is as to whether these effects have any meaningful long lasting effect on the course of any particular illnesses, or can create ‘wellness’ (however you would like to define that). I could smack you with your tennis racket – and that might affect your blood flow to your brain, but your rage may not actually have any (long term) medical effect.
Unlike homeopathy, chiropractic does not completely stand or fall on its mystical foundations. Conceivably, chiropractic could have beneficial effects even if subluxations and so on are all nonsense. Clinical trials are required to answer these questions. Homeopathy can be shown to be nonsense easily. Chiropractic takes a little more care. It is not up to me to do your leg work for you. It is your trade – can you substantiate it? I see little evidence you can.
RL : Andy you disparaged the chiropractic education at AECC as brainwashing and a cult. They fact that you knew the AECC science teachers were medically trained, and the AECC chiropractic tutors were in fact sceptical about chiropractors ability to reproduce their examination techniques would suggest you were being disingenuous when you made those comments. This brings into question your ability to use evidence to improve practice (which is what Sackett intended with EBM) or use evidence to confirm your own prejudices(point 9).
AL: You are putting words in my mouth. What I have said is, is that I consider much of the four years of teaching that goes on in chiropractic college to be mere padding which inflates the students opinions of themselves and justifies the colleges taking £40,000+ off them. Chiropractic students are the first victims of chiropractic. The lack of demonstratable effectiveness in most chiropractic claims makes such an outlay unjustifiable. The students are mortgaging themselves to learn ineffective and discredited theories and treatments. It is certainly not worthy of a ‘career’. Students’ efforts and cash could be much better put to use elsewhere. But in order to maintain this charade, it would appear that a cult-like sense of self-belief, groupthink and denial of criticism has to take place. The AECC itself says that it introduces more science in its courses to “in order to counter accusations of ‘quackery’”. Take away the peripheral science and what do you have left? Simple quackery? Is the extra teaching just a fig leaf to hide the embarrassment that is chiropractic thinking?
RL: I accept your point the scientific evidence for chiro Delete Comment
RL: I accept your point the scientific evidence for chiropractic and many orthodox interventions is not great so you don’t have to labour the point unless you think I should stop practising because of this.
AL: Good grief – well, what do think you should do? You appear to have a few choices – you could stop, or you could embark on a badly needed programme to collect and evaluate good evidence, or you could barrel on regardless of the evidence. Chiropractors appear to be adopting the latter approach. Of course, treatments should cease if they cannot demonstrate efficacy. If the tests have not been done, then efforts should be made to do them. If they have been done and come up negative – such as with the bogus claims of the BCA – then they should be dropped forthwith. I would day this about any medical approach – not just chiropractic. You may well find practices in real medicine that continue despite poor evidence – but do you think that justifies your own trade to march on regardless? (I really hope you do not have the lack of shame to try a tu quoque here.)
RL: Chiropractic, medicine, dentistry, are arts dealing with all the variables members of the public people bring with them, its not an exact science and its only the BCA and GCC sceptics who think it should be.
AL: Straw man. Just what is an exact science? Can you name any? Science is all about dealing with uncertainty and variability and understanding underlying principles despite this. Chiropractic is perfectly amenable to scientific enquiry. It fails.
RL: Nopw we have agreed on your point, will you now deal with my 9 points. When I am looking for “subluxations” I am looking for motion dysfunction in spinal facet joints, unless you are still saying that does not happen and are still saying “subluxations” do not exist which would be another point making it ten 10.
AL: Well, part of the problem is that it looks like the world of chiropractic itself cannot agree what a subluxation is. There are those that appear to cling to the idea that they are spinal blockages of innate (or whatever), others adopt more modern medical words. Crucially, chiropractic hinges on whether their bone crunching back rubs can actually move elements of the spine. And that these movements can aid more general health issues. I would say, as a package, such thinking is still unproven, no matter what language you use. That intra examiner reliability cannot be demonstrated is good evidence that it is nonsense. Which is where we started off