My response to a pro chiropractic response to Simon Singh's article

A critique of Simon's article by Richard Lanigan can be found at: chiropracticlive.

I address some of the points Richard Lanigan makes below:


Beware the spinal trap
by Simon Singh

Simon: This is Chiropractic Awareness Week. So let’s be aware. How about some awareness that may prevent harm and help you make truly informed choices? First, you might be surprised to know that the founder of chiropractic therapy, Daniel David Palmer, wrote that, “99% of all diseases are caused by displaced vertebrae”. In the 1860s, Palmer began to develop his theory that the spine was involved in almost every illness because the spinal cord connects the brain to the rest of the body. Therefore any misalignment could cause a problem in distant parts of the body.

Richard: If I was going to criticise a health care profession, I would say it was important to have all my facts and provide accurate information. DD Palmer was 15 in 1860, worked as a teacher in the mid 1860s, worked as a bee keeper and small famer in the early 70s. The first mention of DD Palmers involvement in “healing” was in 1885 when he became a magnetic healer. It would seem he was in fact developing “developing his theories” in the 1880s rather 1860s, I suspect Simon Singh has confused DD with Andrew Still who founded Osteopathy and was developing his theories about manipulation in the 1860s.

DD Palmer'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. To define chiropractic along these lines is like defining medicine the way Harold Shipman practised.

In fact, Palmer’s first chiropractic intervention supposedly cured a man who had been profoundly deaf for 17 years. His second treatment was equally strange, because he claimed that he treated a patient with heart trouble by correcting a displaced vertebra.

Stranger things have happened. Here we have a news report in 2008 stating a chiropractor restored a mans [sic] sight. I think its fair to say if Palmer had observed Harvey Lillard getting his hearing back he may have thought that he had discover the holy grail of healing. Look at the competition at the time 1895??

Me: Daniel David Palmer was born in 1845 (according to Wikipedia at least) so Richard my be right here and Simon may be wrong. On the other hand, the BCA is not suing Simon for getting his date wrong so I'm not sure how relevant this is. [By the way, "magnetic healing" had nothing to do with magnets and was rather a cross between massage and meridian therapies (according to this source; so Richard's suggestion that Palmer was thinking about magnets rather than manipulation at this stage is misleading.)

As for anecdotal claims that sight or hearing was restored in particular individuals by chiropractic, there is a even a name for this kind of fallacy: The "post hoc ergo propter hoc fallacy."

Simon: You might think that modern chiropractors restrict themselves to treating back problems, but in fact they still possess some quite wacky ideas. The fundamentalists argue that they can cure anything. And even the more moderate chiropractors have ideas above their station. The British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying.

Richard: Whether sceptics want to believe it or not, I have helped children with all these problems. Lets look at “Ear infections” and I will try not to let my “ideas rise above my station”. For many years ear problems have been misdiagnosed by medics and treated ineffectively with grommets and antibiotics.

So what is a clinician to do. Angela Peel White my anatomy tutor at The Anglo European College of Chiropractic was a qualified GP. I never held it against her because she was a brilliant tutor. She told us know the anatomy of the region you are examining. If you look at the inner ear it has “drain” called the eustachian tube. Its narrower at the top, children with small little necks have only a small gradient and the tube does not drain very well. The blockage causes pain due to the discrepancy of the air pressure outside the ear drum and inside. This can also be a problem for inexperienced divers. Who are not able to “equalise” ear pressure as they decent in water.

The biological explanation as to why “manipulation” could help a child with otis media is very similar to how experienced divers equalise when the eustachian tubes are blocked and unable to relieve the pressure on the inner ear as they descend in the water. They crack their TMJ as if blowing rings smoking dope (I am a child of the 60s), this helps open the eustachian tube and equalise the pressure on the ear drum.

There is also a neurological explanation, I will spare the details suffice to say when Professor Ernst or chiropractic sceptics say there is “no biological reason why spinal manipulation should with help ear Infections” the anatomy shows clearly they are talking through their collective arses.

I have four children, young children cannot crack their jaw themselves, the adjustment requires skill and practise, not all chiropractors can do it and that’s a problem when chiropractors enter these clinical trials. I am not an academic, I am just a clinician.

Me: Not quite sure how to respond to this. Yes, "cracking" your jaw can (temporarily) relieve pressure in your inner ear. There are other ways of doing this, and I am not qualified to say whether jaw cracking is the most appropriate strategy for children, but what has this got to do with neurology? Also, what has Richard's claim that he can crack kids' jaws, and some chiropractors can't, got to do with anything? Any sensibly designed clinical trial would address such considerations.

Richard: Then Simon continues to the bit that upset the BCA

Simon: ……..even though there is not a jot of evidence. This organisation is the respectable face of the chiropractic profession and yet it happily promotes bogus treatments.

Richard: First I would question whether the BCA leadership is the respectable face of chiropractic. No One would dispute that the “scientific evidence” is weak for these conditions, which account for a very small part of my practice 5% and I probably see more children than most chiropractors. However if we look at Professor Ernsts own “Hierarchy of Evidence” at the bottom there are “case reports” and “observational studies”. Yes the chiropractic evidence is at the bottom of Ernsts pyramid however “not a jot of evidence” would only be accurate statement if Professor Ernst were to remove the bottom of his pyramid. In addition anyone with a limited knowledge of the politics of the chiropractic profession would know that the BCA leadership with rather stick to musculoskeletal pain syndromes and probably puts childhood disorders on their website to prevent more members from leaving the association. If Simon had directed those comments at the UCA or the McTimoney association the BCA leadership would have been leading the applause.

Me: Here we start to get to the heart of the matter. What Richard omits here is the consideration that real medicine is expected to move up the pyramid of evidence.

If a treatment or observation about a certain existing treatment or lifestyle is novel then “case reports” and “observational studies” do constitute a jot of evidence. If, after a hundred years plus of chiropractic, we still only have “case reports” and “observational studies” as evidence and nothing at higher levels in the pyramid (thinking here of the conditions over which Simon is being sued) then it is perfectly reasonable comment for Simon to say that there is not a jot of evidence.

There is, after all, some annecdotal evidence for almost every nutty thing that can be thought of. Are we to conclude that the phrase "not a jot of evidence for X" be banished from the language?

Simon: I can confidently label these treatments as bogus because I have co-authored a book about alternative medicine with the world’s first professor of complementary medicine, Edzard Ernst.

Richard: What does that prove? Margaret Thatcher was the first women prime minister we can only pray the second one is better. The chapter on chiropractic in “Trick or Treatment” has only three chiropractic references all by the co-author Professor Ernst which should have set alarm bells ringing in a science journalist with a PhD. To pad out the chiropractic chapter they finish it talking about homeopaths and vaccines. I told Simon I did not believe he had written that chapter and it was all Ernsts [sic] work but he says he did write it.

Me: The fact that Simon has written a book proves nothing, it does, however, suggest that Simon has researched the matter thoroughly and that (given that we know that Simon is a highly respected science journalist) his views and claims are worth investigating.

Simon: Ernst learned chiropractic techniques himself and used them as a doctor.

Richard: I can carve a joint, this does that make me a surgeon? Chiropractors spend five years learning to adjust spinal joints. Simon has not visited the Anglo European College of Chiropractic to see how chiropractors develop their skills and Guardian readers are expected to believe professor Ernst thought himself these “chiropractic techniques” over a few weekends and it would appear he was not very good at it, many failed practitioners end up in academia.

Me: The fact that Edzard Ernst learned chiropractic techniques is interesting background information. As, I suppose, Richard indirectly implies, this is of little ultimate relevance to the question as to whether what Ernst says about the generally efficacy of chiropractic is true.

Simon: This is when he began to see the need for some critical evaluation. Among other projects, he examined the evidence from 70 trials exploring the benefits of chiropractic therapy in conditions unrelated to the back. He found no evidence to suggest that chiropractors could treat any such conditions.

But what about chiropractic in the context of treating back problems? Manipulating the spine can cure some problems, but results are mixed. To be fair, conventional approaches, such as physiotherapy, also struggle to treat back problems with any consistency. Nevertheless, conventional therapy is still preferable because of the serious dangers associated with chiropractic.

In 2001, a systematic review of five studies revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches. These are relatively minor effects, but the frequency is very high, and this has to be weighed against the limited benefit offered by chiropractors.

Richard: Arthritis is a chronic condition suffered by millions of British people often it has developed because it was not managed properly when it was just a small ache ( Pain killers and anti inflammatory medication to mask a mechanical problem). In May, the National Institute for Clinical Excellence in the UK published its guidelines for the management of Low back pain http://guidance.nice.org.uk/CG88 . What was extraordinary about these guidelines is that they were stating that doctors should no longer offer; Spinal injections, Traction, Lumbar Supports, Ultrasound, Interferential, Laser and should consider a course of spinal manipulation by a chiropractor or an osteopath or acupuncture instead.

In effect NICE is stating that the orthodox methods for treating back pain has not worked and the evidence is suggesting that it would be cost effective for the NHS to pay for complementary treatments like chiropractic and acupuncture in the future.

Me: First of all we are back to back pain here - not the subject of the libel action or of Simon's more derogatory statements concerning chiropractic. Moreover, the argument used here: "There is growing evidence that many accepted medical treatments for chronic back pain don't really work therefore we should replace them with treatments for which there is no real evidence at all" does not really hold a lot of water - even if some people at NICE are using this argument too.

To those who say that there is real evidence, I say: "show me it" - a test which the BCA have spectacularly failed (again talking of the claims which are the subject of their libel action against Simon.

Simon: More worryingly, the hallmark technique of the chiropractor, known as high-velocity, low-amplitude thrust, carries much more significant risks. This involves pushing joints beyond their natural range of motion by applying a short, sharp force. Although this is a safe procedure for most patients, others can suffer dislocations and fractures.

Worse still, manipulation of the neck can damage the vertebral arteries, which supply blood to the brain. So-called vertebral dissection can ultimately cut off the blood supply, which in turn can lead to a stroke and even death. Because there is usually a delay between the vertebral dissection and the blockage of blood to the brain, the link between chiropractic and strokes went unnoticed for many years. Recently, however, it has been possible to identify cases where spinal manipulation has certainly been the cause of vertebral dissection.

Laurie Mathiason was a 20-year-old Canadian waitress who visited a chiropractor 21 times between 1997 and 1998 to relieve her low-back pain. On her penultimate visit she complained of stiffness in her neck. That evening she began dropping plates at the restaurant, so she returned to the chiropractor. As the chiropractor manipulated her neck, Mathiason began to cry, her eyes started to roll, she foamed at the mouth and her body began to convulse. She was rushed to hospital, slipped into a coma and died three days later. At the inquest, the coroner declared: “Laurie died of a ruptured vertebral artery, which occurred in association with a chiropractic manipulation of the neck.

This case is not unique. In Canada alone there have been several other women who have died after receiving chiropractic therapy, and Professor Ernst has identified about 700 cases of serious complications among the medical literature. This should be a major concern for health officials, particularly as under-reporting will mean that the actual number of cases is much higher.

Bearing all of this in mind, I will leave you with one message for Chiropractic Awareness Week – if spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.

Richard: Which drugs, Viox, Celebrex, statins etc,etc. In 1998 Lazarou et al estimated that 106,000 people die each year from adverse reactions to prescribed medications. Thats [sic] the equivalent of a jumbo jet crash every 2 days and no public enquiry? Professor Ernst has spent the last ten years trying to convince the British and Irish public that chiropractic is more dangerous than medicine.

The tragic story of Laurie Mathiason who suffered a stroke ten years ago while receiving chiropractic treatment in Canada is not convincing “evidence” that chiropractic is dangerous. Every five minutes someone in England will have a stroke(National Audit Office), there are no epidemiological studies that would even hint that this finding has anything to do with chiropractic, yet Professor Ernst goes on repeating his opinion.

I have practised in the same area for almost fifteen years, I adjust the cervical spine of the vast majority of my patients and I don not recognise the “dangerous” practise Simon describes. I have never had a complaint or hurt anyone, occasionally a patient feels worse after the first visit, but thats about it. If patients were having strokes surely I would have heard something and the fact Ernst wont let poor Laurie Mathiason rest in peace because he needs this anecdote to bases the theory on which has created his media profile, dont kid youselfs Professor Ernst is not well known for his research he has become the Jordan of the EBM community, I wonder what David Sackett makes of Ernsts evidence base? The inconsistencies in these arguments by the sceptics are staggering, something happens after a vaccine and its coincidence, anything happens after a chiropractic adjustment and its the chiropractors fault. For a small profession we must be good at hiding our bodies, perhaps thats [sic] where Harold Shipman learned how to kill his patients without anyone noticing.

Me: All medical interventions (both conventional and so called "alternative") have potential risks and benefits. That's why we need to base medical interventions on real evidence. Real evidence is collected when researcher's move up the evidence pyramid cited above. The notion that we can have one kind of evidence to conventional medicine and another "alternative" kind of evidence for "alternative" medicine is simply nonsense.

The real difference between science and woo (in all it's forms) is not that science is all true and woo is all bollocks; the real difference is that (true) scientists (of course individual scientists can be just as irrational as anyone else) constantly revise their ideas and practices in the light of the ever growing body of evidence.

When they found out that Shipman had killed lots of people, the medical profession investigated the evidence that the case provided, concluded that administrative practices had been woefully inadequate, and changed their administrative practices to try and prevent this happening again in the future. Similarly, when the medical profession discovered that Cox-2 inhibitors had an unacceptably high risk for the (far from insubstantial) benefit they were providing, the medical profession changed their practice and stopped prescribing these drugs.

Where are the clinical studies documenting the risks and benefits of chiropractic for infant colic? where are the stories of the chiropractic "profession" changing its treatment of infant colic in response to such clinic studies? Chiropractic just doesn't work like that.

There is some evidence that (non-cracking) massage and manipulation provided by an osteopath, chiropractor, or physiotherapist might help a bit with back pains and aching joints. All the rest is woo!