What you should know about chiropractic ?
Just what is chiropractic, and do the claims of chiropractors stand up to scrutiny?
FOR many people, chiropractic appears almost mainstream. Some chiropractors even call themselves “doctor”. In the UK, chiropractors are regulated by statute, and in the US they like to be seen as primary care physicians. It is therefore understandable if people hardly ever question the evidential basis on which this profession rests.
I would argue there is more evidence in support of chiropractic than any other CAM intervention. Because there is more research it gives sceptics like Professor Ernst some research to criticise and write about. I have no problem with that, perhaps the chiropractic profession would get less criticism from Ernst if they did no research at all. I would have a problem with that and so would my colleagues.
The origins of chiropractic are surprising and rather spectacular. On 18 September 1895 Daniel Palmer, a “magnetic healer” practising in the American Midwest, manipulated the spine of Harvey Lillard, a janitor who had been partially deaf since feeling “something give in his back”. The manipulation apparently cured Lillard of his deafness. Palmer’s second patient suffered from heart disease, and again spinal manipulation is said to have effected a cure. Within a year or so, Palmer had opened a school, the first of many, and the term he coined, “chiropractic”, was well on its way to becoming a household name.
The only true cure
Palmer convinced himself he had discovered something fundamental about human illness and its treatment. According to Palmer, a vital force – he called it the “Innate” – enables our body to heal itself. If our vertebrae are not perfectly aligned, the flow of the Innate is blocked and we fall ill. Chiropractors speak of these misalignments as “subluxations” (in conventional medicine, a subluxation means merely a partial dislocation). The only true cure is to realign the vertebrae by manipulating the spine, and in the logic of chiropractic it follows that all human illness must be treated with spinal manipulations. Many chiropractors also assert that we need regular “maintenance care” even when we are not ill so that subluxations can be realigned before they cause a disease. In the words of Palmer “95 per cent of all diseases are caused by displaced vertebrae, the remainder by luxations of other joints”.
DD Palmers’s hypothesis was that interfering with nerve function would affect optimal well-being, he explained his theory around “displaced vertbrae”. Palmer’s understanding of the effects of spinal manipulation should be viewed in its time (the late 19th century) when surgery had a mortality rate of 76%. I know of no 21st century chiropractor who would explain chiropractic as Palmer did, or a surgeon who would operate in his street clothes without a mask.Perhaps Ernst does know some.
All diseases are caused by ‘subluxations’ blocking the flow of the ‘Innate’
This is bulshit! I have written many articles about this use of the word disease in relation to chiropractic and this is a classic example of people quoting Palmer selectively and out of context. In their efforts to teach medicine at many chiropractic colleges they avoid the history of chiropractic. As a result many UK chiropractors are ignorant when it comes to discussing the origins of chiropractic and are embarrassed about it.
DD Palmer wrote one book “The chiropractic Adjuster” His son BJ wrote many and collectively they are called “Green Books. The book that most accurately describes the teachings of the Palmers was written by R.W. Stephenson’s in 1920 he compiled his list of “chiropractic principles” in his“Chiropractic Textbook”, BJ Palmer praised him for compiling the principles of “my writings into systematic organised manner so anyone could easily find “what chiropractic is, Is not; What it Does and does not; how and why it does what it does not” Lets see exactly what Palmer says about disease.
Modernist chiropractors and sceptics deliberately interpret the principles literally without reference to the time they were written in or the language of that time. The best example is the way they ignore the little weeny hyphen in Palmers dis-ease (Principle 30 “The Causes of Dis-ease”). Stephenson clearly states in the book “Disease” is a term “used by physicians for sickness. To them it is an entity and is worthy of a name hence diagnosis”.
Stephenson describes Dis-ease (with a hyphen) as “a chiropractic term meaning not having ease. It is a lack of entity It is a condition of matter when it does not have property of ease. Dis-ease is the condition of tissue cells when there is uncoordination”. Stephenson goes onto say, “if tissue cells are not coordinating some tissue cells will be made unsound, therefore they are sick and not at ease. By deconstructing chiropractic down to a vitalist level of cell communication we are going beyond nerve interference and into the realms of neuroscience that Candice Perth would describe as the “molecules of emotion” 80 years later. Anyone who would state “subluxation chiropractors” claim to cure all “disease” is either disingenuous or ignorant. I have no idea which one applies to Professor Ernst.
This bit of history is important because it explains why many chiropractors treat all sorts of conditions, not just back pain. In fact, in the early days, back pain was not an issue for chiropractors at all. Today they are divided into roughly three camps. One adheres religiously to Palmer’s gospel – indeed, at one stage Palmer considered establishing chiropractic as a religion. Another has moved on and now employs a range of non-drug treatments in addition to manipulations, mainly for treating back pain. The third group is situated somewhere in between these two extremes and, at least occasionally, treats many conditions other than back pain.
No problem with that I would be in the third group. Harder to tell you which association is in which, they tend to mix and match. BCA would be more group one and presumably why Tony Medcalfe was furious when Simon Singh lumped him in the first group (they are keen on chiropractors having prescribing rights). It was a bit like Simon Singh accusing a homophobe being of being gay and the homophobe needs to show everybody how macho he is and goes to court for defamation. Many chiropractors did laugh when they read the article.
If you find this hard to believe, here is the evidence. A 2004 survey by the UK General Chiropractic Council revealed that most chiropractors believe they can treat asthma (57 per cent), digestive disorders (54 per cent), infant colic (63 per cent), menstrual pains (63 per cent), sport injuries (90 per cent), tension headaches (97 per cent) and migraine (91 per cent). According to a 2007 survey, 69 per cent of all UK chiropractors see themselves as more than just back specialists, and 76 per cent consider Palmer’s original concepts to be “an important and integral part of chiropractic”.
Bloody right, empirical evidence its called. Chiropractic is a separate and distinct profession and those chiropractors who want to turn it into a bio medical speciality for the treatment of pain syndromes. I say “Over my dead body”
So, are they right? Palmer’s concepts of the Innate and subluxation are pre-scientific and wacky, but that in itself needn’t mean that the treatment is not helpful. We therefore need to ask, how good is chiropractic spinal manipulation in treating anything?
What is pre-scientific and whacky about homeostasis and spinal joint dysfunction or innate and subluxation, someone please tell me. I have made some comments on subluxation on the discussion on Guardian.co.uk, and was wondering if any chiropractors have anything to add.
The answer is not clear-cut. For back pain, there is some encouraging evidence. Chiropractic manipulations have been shown in several clinical trials to be as effective as standard treatments. One needs to know, however, that standard care is not very effective for bad backs, and studies that adequately control for placebo effects tend to arrive at less positive conclusions. When my team in Exeter reviewed data from these more rigorous trials we concluded that “spinal manipulation is not associated with clinically relevant specific therapeutic effects” (Journal of Pain and Symptom Management, vol 22, p 879).
For virtually all the other conditions which chiropractors treat, where rigorous trials have been done, the evidence is weaker. In some cases, the most reliable studies have found that spinal manipulation is ineffective.
Chiropractic is a skill, some chiropractors are very good at spinal adjustment and some are crap. The crap ones are now looking for prescribing rights to see if that helps them get better results, if a chiropractor offers you NSAIDS run a mile. These chiropractors will probably end up doing research and teaching at chiropractic colleges (apologies to teachers like Alf, Kent and Chris and others who I know have a vocation to teach) Researchers are not the best judges of who is technically proficient for adjusting in a trial. Not so many variables when you compare a drug to a placebo in a trial. Some adjustments may be no more effective than the placebo adjustment, Just as Andy Roddicks service is more powerful than my service.
You need speed and control to do an effective adjustment some never master it in their entire careers. Chiropractic students are chosen on A level results when in fact the should be chosen on psychomotor skills. What can I say, the evidence is not good enough and does not reflect what some colleagues and I see in practise every day, especially in relation to asthma.
Chiropractors and many of their professional associations often claim otherwise, but a few do acknowledge this problem. In 2001, one team of chiropractors looked at this issue, and their conclusion was blunt: “The largest professional associations… make claims for the art of chiropractic that are not currently justified by available scientific evidence”. Since then, several investigators have come to similar conclusions.
The issue is not just whether chiropractic treatments work. There is also the question of the safety of chiropractic spinal manipulation, a matter that few people seem to be aware of. Several big studies have shown that a large proportion of patients experience side effects after receiving chiropractic spinal manipulation. Luckily these complaints – mostly pain – are not normally very severe and are usually gone after a day or two.
There have, however, been several hundred cases of potentially very serious complications associated with this treatment. Extreme chiropractic manipulation of the neck can damage one of the two vertebral arteries that run roughly parallel to the upper spine and supply part of the brain. The consequence of such a “vascular accident” can be a stroke, and several deaths are on record. Such disastrous events are, of course, rare; this is one reason why it is difficult to investigate this phenomenon systematically and not all studies show the same result.
First let me first say, in 15 years, I have seen thousands of patients in a local community(North Kingston) and i have never hurt anyone and it has never been suggested to me that I have. There is “not a jot” of epidemiological evidence showing a causal relationship between chiropractic and stroke, in fact I would go as far to say this claim is “bogus”. Ernst is relying on anecdotal evidence to support his claims. The exact same type of evidence he criticises the chiropractic profession for using to support the efficacy of chiropractic for treating children. When Ernst uses anecdotes he attaches great weight to them. When chiropractors use them they are worthless as far as Ernst and the sceptics are concerned . Chiropractors are also accused of not presenting the negative studies with the positive. Ernst fails to mention the Cassidy or the Bolton studies, you know the ones which failed to report on what happened next. According to Ernst all the subjects may have died from stroke after their very last adjustment and as there was no follow up on them to see if they are still alive and well, Ernst will not take the studies seriously and presumably thats why they are not mentioned. Ernsts methodology for rigorous scrutiny would appear to rather inconsistent when it comes to his own research.
What’s the follow up in vaccination studies 60 minutes? If a reaction does not happen in the surgery within 60 minutes after the injection the side effect is coincidence according to most studies assessing vaccinations. Sally Clarkes son died three hours after his DTP vaccine and it took years before anyone would consider the possibility that she had not murdered her child and it could have been the vaccine.
In November 2005 “The Stationery Office” www.tso.co.uk Published a report for the department of health “Reducing Brain Damage: Faster access to better stroke care”. The Report states Stroke accounts for 11% of deaths in England and Wales every year. Every five minutes someone in England will have a stroke, and one in four people can expect to have a stroke if they live to 85 years of age.
The Risk of stroke are:
• High blood pressure
• Family history of stroke
• Atrial fibrillation
• High blood cholesterol
• Advancing age
• Unhealthy diet
There is no mention of Chiropractic in this report and despite the fact that there is no evidence of a causal relationship Professor Ernst keeps insisting there is one. Why? because it gets an academic with little to offer the scientific community publicity. He keeps repeating his claims and newspapers keep printing it. Its about as relevant to the health of the nation as Jordan and Peter Andres break up. It sells newspapers that all.
In the book I co-wrote with Simon Singh, Trick or Treatment? Alternative medicine on trial, we dedicate a chapter to chiropractic. After weighing all the evidence, our conclusions were not flattering: “Warning: this treatment carries the risk of stroke and death if spinal manipulation is applied to the neck. Elsewhere on the spine, therapy is relatively safe. It has shown some evidence of benefit in the treatment of back pain, but conventional treatments are usually equally effective and much cheaper. In the treatment of all other conditions chiropractic therapy is ineffective except that it might act as a placebo.”
This chapter in Trick or Treatment devoted to Chiropractic has three Chiropractic references. Three. Even worse they all from the same person. You guessed it, the references are by the author of Trick or Treatment none other than the eminent Professor Edzard Ernst. He is having a laugh isn’t he or does he think we are all like those clowns he presented his research to at the GCC in 2006.
So desperate was Ernst denigrate chiropractic he finishes the chiropractic chapter talking about homeopaths and vaccines, why was that not in the homeopath section? Because he wants to lump us together. I have not vaccinated my children however that is a minority view in the UK chiropractic profession I believe the figure was 70% of UK chiropractors support the governments vaccination policy as this did not siut the point Ernst wanted to make it is not mentioned.
Simon later wrote an article in The Guardian newspaper about chiropractic. In it, he quoted from the website of the British Chiropractic Association which, at the time, made fairly clear claims that chiropractors can effectively treat a whole range of childhood diseases, including asthma. The evidence for treatment of this condition is less than weak: no fewer than three controlled trials have found that chiropractic spinal manipulation has no beneficial effect. The best of these studies, published in The New England Journal of Medicine, concluded that “the addition of chiropractic spinal manipulation to usual medical care provided no benefit”.
For alerting the public to all of this, and possibly preventing harm to unsuspecting children, Simon deserves much credit. Instead, he is being sued for libel by the British Chiropractic Association. I think this is a serious issue that raises two crucial questions. Is it acceptable that scientists and journalists are restricted in their criticism by the legal muscle of those who are being criticised? And is it acceptable that professional bodies, such as the British Chiropractic Association – or indeed any other organisation – are able to make therapeutic claims that are not supported by scientific data? I leave it to the reader to decide.
Ezard Ernst should be allowed to express his opinions publicly, without the BCA calling their lawyers. I will leave it to the reader to decide how sensible his opinions are and wonderwhy the BCA were unable to rebut any of this without involving lawyers and making the chiropractic profession a laughing stock.
Edzard Ernst is professor of complementary medicine at the Peninsula Medical School in Exeter, UK. In his investigations of alternative therapies, he has found only about 5 per cent are supported by scientific evidence; the rest are either ineffective or have not been tested properly.
He would like funding to do research to disprove this 5% and then have his own reality TV show. “Britains got talented quacks”.
Otherwise it is difficult to know what he is suggesting. The health service should continue as is, and the collateral damage from side effects on pharmaceuticals war on disease are an acceptable price to pay.