Many of the statements made by Simon Sing and Edzard Ernst about chiropractic in their book “Trick or treatment” could have been lifted from David Byfields report and testimony in the GCC V Jesper Jensen case in 2002. I have always believed the Jensen case was brought by the GCC in an effort to define the scope of chiropractic practice. Simon Singhs case and the subsequent campaign would help the GCC to define a scope of practice for chiropractic.
Jesper Jensen took down his web site on being informed by the GCC that they were not happy with the content, nevertheless the GCC pursued the case at a cost of about £130,000; which resulted in an admonishment for Jesper jensen. David Byfield was the GCC expert he altered the evidence ( the text on the website) against Jensen 37 times in order to have the debate on subluxation chiropractic the GCC wanted to have, rather than stick to the facts of what Jensen had actually written on his website. I dont believe David Byfield ever gave evidence again. Nevertheless he is a President of the Welch Institute of Chiropractic and a reappointed member of the reformed GCC
I believe the statements David Byfield made in his report and testimony are very similar to the views of Edzard Earnst and Simon Singh; Many of the views Professor Ernst and Simon Singh
Ernst and Byfield are perfectly entitled to hold these views, however they are not representitive of the chiropractic profession in the UK who Byfield is regulating ? Should we limit ourselves to musculoskeletal pain relief? Or is the chiropractic profession a broad church made up of mechanist and vitalist doctors?
On page 6 from David Byfields 2002 report it states “Evidence based practice is recognised as being of fundamental importance in the delivery of high quality health care in the modern world. Accordingly this should be reflected not only in what is performed therapeutically but should also be represented in the information and advice distributed by the practitioner (chiropractic) to his patient population. Anything less than this approach to patient care and advice is careless and misleading”.
On Page 7 Byfield states “There is a plethora of meta-analyses and systematic reviews documenting the effectivness of manipulation for the treatment of low back pain. This information was completely omitted by the Parker clinic website. Instead the website describe chiropractic care of a number of obscure clinical conditions which are not considered within the scope of chiropractic practice within the UK".
When was this scope of practice defined???Or was this the wish list of the GCC?
Page 8 “The potential benefit of manipulative therapy for other musculoskeletal conditions are largely unknown and limited only to case reports. Whats more there is very little evidence to support the chiropractic belief that manipulation can beneficially influence the bodys overall healing capacity. Moreover Dr Jensen failed to report that some of the more dramatic reports and anecdotes regarding recovery from non-musculoskeletal conditions may have resulted from i) original medical misdiagnosis ii) The effect of concurrent treatments iii) remissions that would have occurred regardless of treatment"
Page 9 "Until further studys have been conducted any claims regarding the benefits of SMT must be limited to the known evidence of for musculoskeletal symptoms patterns. At this point it is only speculation as to the possible effects of of manual therapy."
Page 14 "There is scientific evidence to a least consider various theories pertaining to the chiropractic adjustment…..Currently there is insufficient data to consider these theories valid. Therefore any claims other than those observed in good quality clinical trials have to be limited until more data becomes available to explain various clinical observations".
Page 13 "Another omission on the Parker Clinic web-site was reference to the potential risks associated with SMT. There is considerable documentation in the literature more recently outlining potential and serious complications as a result of spinal manipulation particularly of related to the cervical spine. Even though there are a many benefits for a number of benefits for a number of common musculoskeletal conditions, there are also risks and primary care practitioners must always balance risks v benefits in a clinical setting. It was in my opinion extremely cavalier to ignore these risks no matter how small and promote to the public the implementation of SMT for conditions where the evidence is scarce. It is my opinion that reference to the complications of manipulation should have been mentioned on the website".
Page 50) "There is no evidence to support chiropractic maintenance or preventative care other than anecdote at this time. Sound science not outdated philosophical tenets and untestable belief systems must underpin quality chiropractic care now and in the future".
Dafid Byfield concludes his report by saying on page 51) "The chiropractic profession has laboured intensely over the last 40 years improving educational standards, participating in quality controlled trials and developing a body of knowledge to support the effectiveness of chiropractic care for a number of common neuromusculoskeletal conditions. The scientific community heralds these achievements. The tone and language illustrated on the parker Clinic Website is antagonistic and potentially undermines these achievements".
Below are excerpts taken from the transcript of the testimoney David Byfield gave to the GCC hearing in 2002
Page 46 in David Byfields report states; "The concept of holism is an untested metaphor and merely one of a number of unproven belief systems within the chiropractic profession".
The barrister refers to holistic chiropractors as opposed to mechanistic in his cross examination of David Byfield. David Byfields answers to the baristers questions (Q) are marked with an A. What is very revealing are his views of BCA promotional material, which were the central part of Simon Singhs case against the BCA.
This is only a small part of the transcript. Simon Singhs legal team have the entire transcript.
Q In his report, Dr Lanigan defines the holistic approach as focusing on removing interference to the body’s innate healing ability. Do you agree with that?
A There is absolutely no evidence to suggest that —
Q That is page 74 of Bundle I, at tab 3, paragraph 5.1. I am reading it out. What he does is define the two major schools of thought, as he puts it. The first, considers chiropractic to be a limited biomedical specialty for the treatment of certain muscular-skeletal disorders. The second school sees chiropractic as a separate and distinct discipline in the healing art, focusing on removing interference to the body’s innate healing ability. Do you accept the second statement as a reasonable definition of the holistic approach to chiropractic?
A No, I do not.
Q Why not?
A Because, first of all, the statement does not say anything. There is absolutely no evidence to suggest that removing interference to the body’s innate healing ability has anything to do with a person’s health. It has never been substantiated; it has never been subject to scrutiny or experimentation, so I think it is an inaccurate statement.
Q You do not agree with it?
A I do not agree with it.
Q In so far as Dr Lanigan says that that is a statement that is a summary of the holistic position, you would say that it is not.
A I would state that the terminology "focusing on removing interference to the body’s innate healing ability" is a philosophical construct that has never been subjected to any investigation. It is purely anecdotal and it has no substantiation apart from some of the roots of chiropractic, which date back into the beginning of the last century.
Q The question of whether it has any substantiation is a question of your own approach, but as a statement of what holistic practitioners believe, do you accept that that is a fair statement of what holistic practitioners believe?
A No. The definition of holism is the body is a sum of all its parts; in other words, a person will take care of the mental, physical and spiritual side of a person’s health care. That does not say that.
Q Your objection to it is that there is no substantiation to the idea that general health the can be improved by removing impediments to it.
A It is a concept. I think, as we have been discussing, information that is provided to the public regarding their health care, and health care decisions, should have some substantiation and should have some reference to peer review literature. I feel that it is important that practitioners, whatever their school of thought -I do not think that is understood; I think it is understood in terms of language, style and tone — the inference of the information and not whether or not Dr Jenson is practising as a holistic practitioner. That is not the allegation.
Q No, but the point I am putting to you is that you do not accept that that statement Dr Lanigan makes about the holistic school is accurate, or is an accurate summary of the way holistic practitioners practise.
A Let me put it this way. This is, I guess, the essence of the debate that is going on with the profession, and would be the divide between the two schools of supposed thought.
Q You would put yourself on the other side of the divide.
A I would put myself hopefully on the balanced side.
Q Are you a member of the BCA ?
A Yes, I am.
Q If you turn to Bundle 5 and go right to the end to page 669 to the second paragraph:
"Chiropractors use their hands to adjust the joints of your spine and extremities where signs of restriction in movement are found. Improvement with mobility and relieving pain. Your body’s own healing processes, which we normally recognise as ability to heal bruises, cuts and broken bones, will then be able to get on with the task of improving your health. This treatment is known as adjustment or manipulation. "
This is a British Chiropractor Association leaflet. Do you agree with that statement?
A This is the first time I have actually read this, so you will have to bear with me. There are some problems with it.
Q What are the problem?
A "Your body’s own healing process, which we normally recognise as the ability to heal bruises, cuts and broken bones." What else have we got here? Yes, it is reasonable.
Q The problem, as you see it, is the suggestion that manipulation will allow the body to improve its general health, is it not?
A I have a problem with that actually, yes.
Q Because that is a holistic concept, is it not?
A It is also a normal physiological process, that whether or not you cut yourself or your break a bone, having chiropractic treatment is not going to accelerate that, is a natural homeostatic mechanism, a physiological process, and I do not think chiropractors have ownership of that.
Q You are not happy with this statement of the position by the British Chiropractic Association of which you are member.
A As I say, this is the first time I have read this. I do not subscribe to the BCA’s promotional material. So, as I say, this is the first time I have read this. It would be difficult for me to really comment on it fully.
Q Go to the next paragraph:
"Poor, inadequate or incorrect function in the spine can cause irritation of the nerves that control our posture and movement. This spinal nerve stress, which may be caused by factors such as accident, poor diet, lack of exercise, poor posture and anxiety, can lead to the symptoms of discomfort, pain and even disease, which are warning that your body is not functioning properly."
Do you agree with that statement?
A No, I do not agree with it all. No.
Q That statement too, is on the holistic side of the divide we have just described, is it not?
A Quite possibly, yes.
Q You are familiar I know with the ACC paradigm, are you not?
Q Can we look at it? It is at page 241, which is about a quarter of the way in of Bundle five. The ACC paradigm, was adopted by the World Federation of Chiropractic, which comprises the National Association of Chiropractors in 77 countries. It is in the second column, one paragraph from the bottom, beginning "By agreement". Have you seen that?
Q The WFC circulated the paradigm to its members in November 2000 and they adopted it in May 2001.
A Can I clarify that the ACC paradigm was accepted by a large majority of participating countries. However, Northern Europe, including the BCA or the UK, Denmark Sweden, Norway voted against it or abstained.
Q I want to establish that there is a substantial body of chiropractors worldwide who do subscribe to it, and you would accept that.
A The evidence is there.
Q Turning to page 238 at the beginning of it, the middle column beginning "ACC position on chiropractic":
"Chiropractic is a health care discipline which emphasises the inherent recuperative power of the body to heal itself without the use of drugs or surgery."
Do you agree with that statement?
A There are some problems with that statement.
Q What are the problems?
A First of all, using the body’s natural recuperative powers is, again, a physiological process. Whether or not there requires any intervention in order to allow that process to move forward is again a statement that may have some difficulty with.
Q Essentially it is the same difficulty you expressed with the BCA leaflet that I just took you to, is it not?
A I am just trying to look at the facts and what these words actually say. They all sound very nice; they all sound very holistic and patient focused. However, if you critically analyse some of these particular statements it is really not saying very much. In fact, it is over-stating the effect.
Q The point I make is this: to the extent this also talks about the inherent recuperative power of the body to heal itself, you had an objection to that which is the same sort of phrase about the body’s power to heal itself that we saw in the BCA. Is that correct?
A I have a problem with the inherent recuperative powers, because if the body does have inherent recuperative powers, would the person require any therapeutic intervention? There are some statements, or some further qualifications of that particular statement, that are missing and could possibly be misleading.
Q It is too far on the holistic side of the divide for you to accept.
A If you critically look at it, it is well beyond that, because there is little evidence -in fact clinical evidence -to support that statement.
Q It is too far on the other side of the holistic divide, is it not?
A Mm (Assented).
Q You see, Dr Lanigan will say that he is a holistic practitioner who would endorse the BCA definition I have taken you to in the previous leaflet; Dr Jenson is too, and so is Dr Carpenter. You accept, do you not, that they are a perfectly respectable body of chiropractic practitioners in this country, do you not?
A They belong to the BCA and they are registered chiropractors, yes.
Q You are happy to say in public that they are perfectly respectable, responsible chiropractors, are you not?
A I do not know how they practise, so I really cannot qualify that statement. I know them as colleagues. There is some history in the country and I know who they are, but how they practise and their practice methods -I have never observed them treat; I have never observed their practices, so I cannot really qualify that.
Q Are any chiropractors in the United Kingdom who practise holistic methods and endorse the ACC paradigm, are they outside the mainstream of chiropractic, as you see it?
A Again, that is their personal choice. I would bring to your attention the fact that the ACC paradigm was recently voted against by the membership of the BCA at a recent special general meeting. I would say there probably would appear to be a majority of chiropractors in the United Kingdom who do not accept the ACC paradigm as it stands.
Q But a substantial minority do, do they not?
A I do not know what you mean by "substantial minority".
Q If a majority do not, it implies that there is a substantial minority that does, does it not?
A Chiropractors in the country can practice whatever chiropractic they want; they can practice as diverse as they want; they can practice whatever methods they want. They still have obligations with respect to the Code of Practice and the standards of safe and competent practice. Whether they believe in the fact that they treat holistically, or whether they believe in the recuperative powers of the body is immaterial in my estimation, in my opinion, with respect to their obligations as a primary care registered chiropractor in this country.
Q You acknowledge that there are a substantial minority of chiropractors in this country who practice the holistic approach with which you do not necessarily agree, but you said they are entitled to practice, as long as they comply with the Code. Is that right?
A In my estimation a chiropractor has an obligation, a statutory obligation in this country, to practice chiropractic as per the Code of Practice and the standards of safe and competent practice, whatever his philosophical tenets are; whatever drives that individual on is his own personal situation. Chiropractors have to suspend, in my estimation, their personal beliefs in the best interests of the patient. I think that is a very important point to make. So whatever their philosophical thoughts about holism I feel the patient’s welfare is paramount, no matter what philosophical thought you may have, or whatever construct you develop your practice by.
Q Does it come to this: you might, as a holistic practitioner, have a belief in the efficacy of the body’s innate ability to heal itself and cure a range of disorders -cure is the wrong word -and lead to benefits in general health -you might hold them sincerely and truly; and while you can practice on that basis while you hold those beliefs, you cannot advertise them on a web site. Is that your position?
A I think, as I said before, I think a chiropractor, as a primary care practitioner in this country, has a responsibility and an obligation to the public to provide them with information that is accurate and not misleading. Under those circumstances, a practitioner should not provide care based on his beliefs, or his or her beliefs; it should be based upon some clinical evidence of efficacy and safety. Under those circumstances, I feel that if you are making decisions based on a belief, then I think that you are contravening the Code of Practice, and possibly taking that patient – and not providing them with the appropriate care.
Q Belief is based upon the experience of clinical practice. Practitioners will say, "We know from our practice that we treat people for muscular-skeletal conditions and they report benefits in general health that go beyond that". That is a completely acceptable way to proceed, is it not?
A There are clinical anecdotes and clinic experience is a valuable tool to add to one’s overall practice approach. However, I feel that the patient’s needs have been incorporated into that, as well as some evidence from sound clinical research. So it is decision-making that is based upon sound clinic evidence, the practitioner’s experience, best practice habits and the patient’s needs. So the belief situation could undermine the patient’s safety and welfare.
Q Belief though, as I pointed out, is not free-standing; it depends on the clinical experience of the practitioner, as you have just accepted.
A Clinical experience is a very important tool and in fact I feel that decisions again should be made upon clear clinical evidence, appropriate procedures and not based upon what you think the patient will benefit from.
Q But if you observe, as a matter of clinical reality, the improvement in your patients that goes wider than simply muscular-skeletal improvement following manipulation, following treatment, then it is reasonable, is it not, as a matter of practice, to take your professional experience of the reports of improvement as a rationale underpinning your mode of practice, is it not?
A I would deem that wholly inappropriate, because to generalize findings on one patient to another patient may be totally inappropriate and inadequate, based upon the clinical presentation. I feel that chiropractors do not measure in way clinical outcomes. In fact, I see patients, let us say with low back pain. They come in; “Are you sleeping at night, Mrs Jones?" "No, I am not sleeping." If their pain comes down, they are sleeping better at night. "Mrs Jones how is the medication going?” "I am taking less now. Thank you very much.” So there are lots of other clinical benefits that you see, based upon pain resolution and improvement in overall function. But to extrapolate and generalize to your entire patient population and advertise that on a website, or any promotional material, I feel is probably unprofessional and inaccurate.
Q By if your experience as a holistic practitioner is that the body’s innate healing ability appears to lead to benefits beyond the muscular-skeletal, and the patient reports in your clinical practice have led you to believe that, there is nothing to stop you, as you say in your report on section 93, practising on that basis, but there is everything to stop you putting it on a website, apparently; is there?
A. I think it is tenuous at best; particularly extrapolating information, even from one’s own experience to a patient. Also it is a well-known fact that throughout Europe most people come to chiropractic with muscular-skeletal disorders. So in other words, 95 percent of patients coming to a chiropractor’s office have either headaches, lower back pain or neck pain. Less than 5 percent – in some studies it is actually less than 1 percent -are non-neuro muscular-skeletal. So, in other words, in Dr Lanigan’s practice, in Dr Jenson’s practice and Dr carpenter’s practice the majority of their patients are going to be coming in, based on that evidence and information, with neuro muscular-skeletal conditions, pain syndromes. To extrapolate that to other conditions, which have been depicted on the website is, I feel, wholly inadequate because of the lack of evidence to support that.
Q But they all say, "Our experience is that this is in fact what happens in our clinical practice. Other conditions are improved following manipulation and therefore we describe ourselves as holistic practitioners in a broader sense that perhaps you would. You would not quarrel with that, would you?
A I would like to ask the practitioners whether or not they actually document that. Are there any case studies, or any outcome measure studies, that would indicate that they are actually showing a difference in a group of patients with those particular symptoms, or with that particular diagnosis. They are not taking into consideration whether there has been a medical misdiagnosis, where there is on-going medical care and whether there is a natural history; things get better.
Q You have already accepted that clinical practice and experience are very important factors in the way in which you decide to treat patients. You now say that if people treat patients on a holistic basis, and make assumptions about their clinical experience in the way that conditions improve generally, you say that is something they cannot do unless they have hard evidence like a randomised control trial, or something of that kind?
A No. I am not saying that at all. I am just saying that I feel there has to be some documentation to indicate that there is some clinical benefit.
Q So there has to be something written down?
A Not necessarily written down. Yes; why not? Why should chiropractors not be involved in the fact that chiropractors are moving towards outcome studies to document clinical outcome there are no studies. In fact, there was one study
Laboeuf, 1999, that actually looked at some of the non-muscular-skeletal effect~ of chiropractic care.
Q She found that 24 percent of them received benefits that were not muscular-skeletal, did she not?
A She found that there were benefits. However, she also said -which is important to qualify -that because the trial was not controlled, the conclusions have to be guarded and taken with caution. She also suggested that further research be done in this particular area. Until that time, any unsubstantiated claims regarding non-muscular-skeletal effects of manipulation should be cautioned.
Q But the logic of your position therefore, if something has to be documented in order for anybody to proceed upon it, is that the clinical experience of practitioners is not enough of a basis to treat patients in holistic terms. Is that your position?
A Clinical experience is a very important part of chiropractic practice; it is a very important part. Once again, I allude to the fact that a chiropractor’s obligation is to assess the health status of the individual. If that individual has conditions or symptoms that may not be muscular-skeletal, it may be some other on-going serious disease, then he may be giving the patient unrealistic expectations of his or her treatment which may be inappropriate and would deter from the appropriate treatment given.
Q So the reason you do not accept it is because you think there should be something more than clinical experience before you start to treat patients for the wider benefits that many chiropractors believe chiropractic gives.
A To make these types of claims, to make these sweeping claims that chiropractic helps all these different conditions, I would expect that under our contemporary health care system, where there is a movement towards evidence-base, and there is pressure for all practitioners, particularly regulated practitioners, to move towards evidence to use the evidence; at the same time, to bring in clinic experience and also the patient’s needs. So it is not necessarily evidence alone or efficacy alone. There is also the experience. If there is no evidence, then best practice methods should be utilized.
Q So we agree that you do not think a randomised control trial is necessary in order to substantiate practice. You have already agreed that. Is that correct?
A There has been some debate about RCTs (randomised control trials) in that they may not, because they have been whittled down to a particular symptom or condition, they may not simulate clinical practice. There is a move towards outcome measures, or practice-based outcomes research, which would more or less demonstrate a more typical clinical situation. I think under control conditions, these particular experiments would and possibly may in the future demonstrate efficacy in different areas.
Q But you agreed a moment ago –correct me if I am wrong –that you were not saying that a randomised control trial was the only way in which practitioners could be satisfied that they could pursue a certain treatment. At the other end of the scale you said that evidence-based practice is important and clinical experience is important. Is that correct?
A That is correct, yes.
Q Somewhere between the two is the point at which it is reasonable for practitioners to practise on holistic principles, if they, as a matter of clinical experience, experience that patient report improvements. Is that correct?
A As I mentioned earlier, I am not concerned about how Dr Jenson practises. I am not concerned about his -that was what I was asked to do when I was asked to do this report; I was not concerned about his philosophical style, his practice patient base -I had no concern with that. What I am concerned about, and what I was asked to comment on, was whether or not the wording, the tone, the inference, the content and style of the website -does it contravene the GCC Code of Practice at 8.4 and 8.5. We can discuss this all day long.
MR EVANS: (To the witness) I will put it specifically to you. If you turn to page 59 of your first report, Bundle 1, tab 2, page 59:
"The concept of holism is an untestable metaphor and merely one of a number of unproven belief systems within the chiropractic profession and may confuse the readership."
Is that what you believe holism is, an untestable metaphor and an unprovable belief system?
A Yes. Under the definition of holism, which is again the view of a patient physically, mentally and spiritually, that is the definition of holism; the sum is greater than the parts.
Q Can you turn to page 42 of this report to the second paragraph?
"(ii) To say the body will function better subluxation-free is misleading and inaccurate and at best an unproven philosophical construct that is yet to be fully investigated."
Subluxation is obviously an important part of the holistic approach, is it not?
A Once again, subluxation is again a very controversial issue, particularly if you go to look at the definition of a medical subluxation versus a chiropractic subluxation.
Q We will come to that in a moment. I am asking you a narrower point at the moment, which is what you are saying here is that the holistic approach is misleading and an unproven, philosophical construct. Is that correct?
A No. What I am saying here is that "The body will function better sub-luxation free" is misleading. I did not say anything about holism here. What I am saying basically is that subluxation currently is theoretical and unproven. It has never been clinically identified.
Q I am putting to you that the subluxation is a central tenet of the holistic approach to chiropractic. Is that correct?
A I think that again it is a central tenet of those who practise subluxation-based practice; not people who practise holistically.
Q Taking up the last points before moving to your report in detail, you accepted that randomised control trials have limits and people are looking to other ways of testing more objectively their experience in chiropractic.
A I stated there is some debate regarding the RCT. The RCT is still considered to be the gold standard of clinical experimentation, but the debate being that it does not necessarily comply with all the other finer nuances of a clinical encounter with a patient. Therefore there are researchers in the profession that are moving towards outcome based research, which is taking place within the confines of clinical practice.
Q If a chiropractor’s practice shows in his clinical experience that, for example, chiropractic can help bed-wetting in his experience, that is something which he is quite entitled to explain to patients and advertise, if he wants to, is it not?
A I do not think so, no.
Q What should he do?
A Under those circumstances the chiropractor should embark upon a clinical trial to look at that unexplained clinical phenomenon and investigate it in the appropriate fashion before he can make sweeping statements about the effects of chiropractic care on bed-wetting. Anecdote alone is not a way to advertise your clinic and then to draw in a number of other patients who may be denied other appropriate care for that particular condition.
Q So chiropractic cannot treat expectantly on the basis of clinic experience, unless they have first conducted a trial.
A Could you repeat that please?
Q You just said you cannot advertise things without doing a controlled trial. Does that mean that chiropractors cannot treat expectantly for conditions such as bed-wetting unless they have first carried out a trial, which is what you have just said?
A No. I am saying that if a chiropractor wants to generalize these statements to a larger part of the population, then he must have some evidence to support that generalisation to the public and therefore be able to categorically announce that he is able, with his methods, to treat bed-wetting.
Q So he can treat without a trial but he cannot advertise without a trial. Is that what it comes to?
A I am just saying that the chiropractor, under those circumstances, it would be inappropriate for him to advertise or promote his treatment of bed-wetting, for example, based upon clinical anecdotes. In other words, a patient comes in who is a confirmed bed-wetter, for him to say, "Yes. I can categorically help you" without the appropriate evidence may be misleading the patient.
Q Look at the first page, "Introduction to the website", because he is not categorically saying anything of the kind. All he is saying is patients report a wide range of improvement. Many different conditions can be treated effectively. He is not saying they will be?
A How do they make those decisions?
Q He is not saying it is categoric; he is saying that as the result of anecdote, the chiropractors here -the patients report a wide range of improvement, which you would agree with.
A But that could be seen as misleading them. In my estimation, for a person to see that without the appropriate clinical trials to support the effectiveness of chiropractic in that particular instance would be misleading the public. So parents who have a bed-wetter, who are extremely distressed, who are looking for any sort of help for their child, would see that website and say, "Yeah. I’ll try that," and that might not be appropriate. Leboeuf in 1992 showed categorically that chiropractic for bed-wetting, for nocturnal enuresis, is not an effective tool. In fact, alarm mats provide better results than chiropractic care.
Q First of all, as a statement, let me put —
A Did Dr Jenson put that on his web site?
Q "Patients report a wide range of improvements." In your clinical experience is that a true statement?
Q Many different conditions can be treated effectively with chiropractic". As a matter of clinical experience, is that a true statement? .
A Yes, and with some of the conditions he lists there, there is good evidence to support what he says.
Q Also one more general topic of subluxation. This is a concept of which you have some criticism, is it not?
A Yes, it is.
Q Why is that?
A I feel that the term "subluxation" has a definition. It has a medical definition and it can be found in any medical dictionary. It is part of our language. Subluxation is defined as a partial or incomplete dislocation of a joint.
Q In medical terms?
A Under subluxation.
Q So you are saying that is the definition, just the medical definition, as opposed to the chiropractic definition.
A That would be the considered medical definition.
Q It is a well known term in chiropractic, is it not?
A It is a term that is used, yes. It is not considered to be a diagnosis though.
Q It is a well known and well used term.
A It is a traditional term developed at the turn of the last century. It has been part of the chiropractic heritage or tradition for a number of years, yes.
Q To the extent that Dr Jenson uses it within the website, you say that is inappropriate, do you?
A I believe it is, yes, because he does not clarify what the terminology is. I feel that is inappropriate because the public should not be confused by this type of communication; they should know full well what these definitions are.
Q It is a term used by many chiropractors in this country, is it not?
A I do not know.
Q You do not know?
A I cannot tell you that. I would imagine there are a number of chiropractors who use the definition in the country, yes.
Q Yet you call it a clinical myth.
Q Why is that?
A I call it a clinical myth because it has never been clinically identified, experimentally identified. It is a theory at best and it would be regarded as very illusive.
Q It means a reduction in the relative segmental movement in the spine, does it not?
A There are over a hundred synonyms for the term "subluxation".
Q Is that a reasonable synonym?
A I would imagine it would be, yes; a reasonable description.
Q In your book, which Dr Lanigan quotes in his report, and no doubt you have seen, "Chiropractic Manipulative Skills", edited by you in 1996 (For the reference, it is Bundle I, tab 3, page 81 ), on pages 26 and 27 you say:
"For chiropractors, however, segmental instability is but one clinical entity that we may encounter. Close to home is the spinal fixation, subluxation, dysarthrosis or biomechanical dysfunction that we locate in almost all our patients. Call it what you will, it represents a perceived reduction in relative segmental motion."
Is that correct?
A Could I clarify that? That was a chapter written by Michael Kondraci and not written by myself.
Q Do you disagree with that?
A He was using it in the framework of all the different terminologies used. I can see his point. He has utilised it in its context with other definitions of the manipulatable lesion, so to speak. I should clarify that I did not write that.
Q Do you think you are over-stating it to call it a "clinical myth"?
A No. I think under the circumstances, using a term that has over 100 synonyms to describe it, a term that has definition within the medical community as a partial or incomplete dislocation, and with some of the other traditional aspects of its definition and its development over the years, I feel that because it has not been identified experimentally, I think at the present time use of the term loosely like that has its problems.
Q One of the things you have criticised Dr Jenson for is failing to draw the risks of chiropractic to the public’s attention. You do that on page 26 of your report at tab 2. You say that it was cavalier of him to ignore the risks associated with manipulation. You draw attention to them: the risk of stroke (one in 1.3 million cervical manipulations); and disk herniation (one in l00 million lumbar manipulations). You said in your report “it is extremely cavalier to ignore these risks no matter how small, and that “reference to the complications of manipulations should have been mentioned on the web site.” Does that remain your belief?
A I feel that under the circumstances, and with the information that was included on the website, all the different conditions that Dr Jenson considered chiropractic to be beneficial for, I felt that with any therapeutic procedure that indicating the risks of manipulation would be an advisable procedure. Again, this is my opinion.
Q Yes, but the risks you talk about are tiny; vanishingly small.
A They are small. They are rare events. However, we have an obligation in this country to acquire informed consent from patients. Part of that process is to establish any therapeutic risk and to try to communicate that with a patient in order that they know there are possible deleterious effects of the treatment, no matter how small.
Q But the risk for stroke, in percentage terms, is 0.000077 percent, and for herniation 0.000001 percent. They are so small. No doubt you have heard of the one percent test in medical consent?
A Yes. We have an objective in the United Kingdom to acquire informed consent from the patient, which also means indicating if there are any therapeutic risks, and there are a number of risks, as I have mentioned here. Although they are rare, they do occur. I think patients should be informed of these particular risk, no matter how small they are.
Q But chiropractic is remarkably safe, is it not?
A It is a safe procedure, yes.
Q You are saying that every time chiropractic is mentioned a chiropractor ought to draw attention to these tiny risks you documented here, fractions of a percent?
A I am saying that to say chiropractors are obligated to inform the public and inform their patients of the more serious effects such as these, and the uncommon effects of manipulation, of manual treatment.
Q But you are saying that there is an express duty to warn of these two remote risks.
Q So every patient who you treat, do you warn them of these remote risks in turn?
A Yes, I do.
Q Every time? Can you turn to tab 3 of Bundle 1 at page 175? This is the BCA leaflet. You are member of the BCA.
"Is chiropractic safe even if I have already had surgery? Chiropractic is remarkably safe when treatment is carried out by a properly trained practitioner".
There is no mention of risk there, is there? There should be, in your view, should there not?
A Yes. We have an obligation to inform patients. Again, the material put out by the British Chiropractic Association unfortunately does not reflect the obligations as put down in the Code of Practice and the Standards of Safe and Competent Practice.
Q Here the BCA leaflet is being extraordinarily cavalier in not highlighting these risks.
A I would say that the BCA currently produces informed consent documents for their members to use to acquire informed consent for examination, to get informed consent treatment and to get informed consent for x-ray examination as well. So from that perspective, I would say that the BCA is being very responsible in providing the members with information to acquire informed consent.
Q Yes, but in this general leaflet, which is an introduction to chiropractic published by the BCA they do not mention the risks. In Dr Jenson’s website he does not mention these tiny risks, but you say it is extremely cavalier of him not to. So it must follow, must it not, that it is also extremely cavalier in your view that the BCA does not expressly mention these tiny risks on page 175?
A I am not quite sure when these were published, the BCA pamphlets.
Q What is the answer to my question?
A I am trying to look at the timing of these, and saying to you now that the BCA now has policies in place to inform members that informed consent, and appropriate documentation of informed consent, is a necessary professional requirement. That is what I am saying.
Q But this document does not mention the risks, does it?
A This document is not under any allegation.
Q This document does not mention the risks, does it?
A It does not, and it should mention the risks.
Q Dr Jenson did not mention the risks, did he?
A No, he did not. It was my opinion, after reading through the documentation, that -again; my opinion- I felt he should have indicated that there are risks to chiropractic treatment.
Q You went beyond that. You said it was extremely cavalier of him.
A It was.
Q Therefore all I am putting to you is that it must follow, must it not, that you would say it is extremely cavalier of the BCA here not to mention the risks? .
A I am not critiquing the British Chiropractic Association A leaflets. I have not been asked to do that, so at this point I had no comment on that. I was critiquing the Parker Clinic website. I made an opinion. You can extrapolate, if you like, but I am saying I have not been asked to review these particular documents.
Q I am asking you to.