Behold the jot of evidence

October 17th, 2009 by Ben Goldacre in bad science, legal chill, libel | 65 Comments »

Ben Goldacre, Saturday 17 October 2009, The Guardian

For those with the finances to try to silence their critics, this has been a week of spectacular own goals. Trafigura has loudly advertised the report on the dumping of toxic waste in Africa by taking out a super-injunction through Carter-Ruck. And on Wednesday Simon Singh, the science writer being sued by the British Chiropractic Association, won his right to an appeal.Briefly, Singh was sued by the BCA over an article in the Guardian in which he criticised chiropractors for claiming they can treat children’s colic, sleeping and feeding problems, ear infections, asthma and prolonged crying, by manipulation of the spine. He said these interventions were “bogus”, with “not a jot of evidence”. Before this case most people hadn’t really noticed chiropractors. Now the internet is awash with reviews of the evidence and its flaws, so this is a good time to revisit the evidence.

Richard Brown, vice-president of the BCA, writes in the British Medical Journal (the article is open-access) that there is “substantial evidence for the BCA to have made claims that chiropractic can help various childhood conditions”. He provided references to 19 academic papers. These have now been examined and effectively demolished in a response by Edzard Ernst, professor of complementary medicine at the Peninsula medical school, Exeter. I am happy to see that someone else has done this work, and I will now walk you through his summary.

Four of the BCA’s references do not contain data about chiropractic treatment for the conditions being discussed, and so are irrelevant. Eight refer to types of evidence that can tell us little about whether a treatment works: questionnaire surveys, case reports and so on. That’s 12 of the 19 references out already.

Among the rest, we are given a small pilot study, by Mercer and Nook, but it is unpublished, and the short conference summary that is available does not have enough information for anyone to know whether their methods were sound.

We are given a trial by Wiberg et al, in which 50 children with colic got either chiropractic or dimethicone: they found less crying in the chiropractic group, but because the babies and parents could not be blinded – they knew which treatment they were getting – even the researchers themselves felt this improvement might be due to a placebo response, or other non-specific effects unrelated to the chiropractic treatment, such as extra attention.

Hawk et al have a systematic review of various types of spinal manipulation for non-spinal conditions and look at the treatment of asthma, otitis and colic. Systematic reviews examine trials and summarise them. They give a positive conclusion for the treatment of asthma, but this relies on a study about osteopaths manipulating the ribs, so that’s not relevant.

They are also positive about colic, to be fair, but, for evidence, they rely on the flawed and unblinded study by Wiberg, described in the previous paragraph. This review therefore adds nothing.

There is a Cochrane review looking at various treatments for bed-wetting, and Cochrane reviews are high-quality summaries of the evidence, as you will know. This one found two trials of chiropractic, which were not of high quality – in fact, the authors described them as “weak evidence”. So that’s not good.

Browning did a trial – which was published after Singh’s article – comparing spinal manipulation with occipitosacral decompression. Both are dubious treatments, and the trial found no difference between them. So both may be effective, or both may just be equally ineffective; either way, no prize.

But most interesting are the studies which the BCA chose not to mention: three randomised controlled trials and two systematic reviews, arguably the strongest evidence, were omitted. The BCA is aware of these studies, because it has specifically commented on other work based on them. So why did they not explicitly reference them? I don’t know. But they are negative papers, which failed to show that chiropractic was effective; while quoting irrelevant papers, questionnaires, case studies and weak trials, the BCA ignored these higher-quality studies, with their unflattering results.

There are huge, endless debates to be had on our libel laws, on the risks they pose to the public by stifling access to information, and on the changes that could be made. But, for today, know this: there is no good evidence that chiropractic is effective for the conditions claimed by the BCA, for the reasons you now know. Shout it from the highest rooftop, when you tell your friends about Trafigura, because, until the law changes, the strongest disincentive to this effect is a very close examination of the companies involved.


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65 Responses



  1. HypnoSynthesis said,

    October 17, 2009 at 4:45 pm

    Another type of evidence… In a survey of about 490 back pain sufferers in 1994 followed by another survey of over 2,000 in the UK, Klein found that the number who reported lasting improvement was about a third. That’s about the same as the average for other therapies across the board, so it may well represent the “non-specific” effect of general attempts to help oneself, or a combination of the placebo effect and spontaneous remission. In the US sample, chiropractic fared quite badly compared to physiotherapy, for example, which benefitted 67% of people long-term.

    This isn’t a clinical trial, it’s a bit like asking for a customer satisfaction rating, though, and finding that only a third of your clients actually found that your service worked for them. That’s not something chiropracters would want to headline in their adverts, though, as the treatment in question is moderately expensive.

  2. Sili said,

    October 17, 2009 at 7:37 pm

    I find it hard to believe that the obviously deliberate exclusion of negative studies, does not support the claim that they’re being knowingly deceptive – bogus, if you like.

  3. Dr Vincent said,

    October 18, 2009 at 12:16 am

    Research evidence is not just RCT’s, neither is all research inquiry suitable for this quantitative paradigm. However, because RCT’s are considered such compelling evidence there is a tendency to rely exclusively on them and for researchers to use the methodology even when to do so may not be appropriate. RCT’s are suitable where the population is homogeneous and the treatment approach uniform. Chiropractors exhibit varying degrees of skill and make use of a number of treatment modalities making the design of RCT’s challenging. Some procedures are similar to those employed by osteopaths and physiotherapists, so it is clearly not unreasonable to rely on evidence from these professions. Cherry picking research is unhelpful, but then so is the slavish reliance on RCT’s. We shouldn’t forget that Thalidomide was considered safe until a case series demonstrated its catastrophic effects.

    The chiropractic profession does not have access to the vast sums of money available to the medical profession and so finds it very difficult to undertake large population based studies. Furthermore there is much to be said for outcome based research, cohort studies and qualitative research methodologies when looking into heterogeneous populations and skill based therapies.
    Manual therapy as practised by chiropractors, osteopaths and physiotherapists requires much more qualitative and quantitative research to be undertaken if we are to fully understand those aspects of treatment that are the most effective and the best way for such care to be delivered.

  4. pv said,

    October 18, 2009 at 12:26 am

    In science, as I understand it simply, when your hypothesis has been shown to be false, to be not confirmed by the best quality experiment, then it is discarded and you move on.
    With chiroquackery and practically all that is referred to as “alternative medicine” (or “alternative reality medicine”, as I prefer to call it) the reason it survives is because there is money to be made from people’s credulity.
    When quacks take refuge in the British libel laws you can be sure they are more worried about the flaws in their business model being exposed than any damage to their reputations – the maintenance of which are contingent on their business model being not being exposed, and very little to do with medicine.

  5. Dr Vincent said,

    October 18, 2009 at 12:59 am

    All theory is a work in progress, as facts are confirmed so we are able to review our understanding, not everything is known. As we refine our knowledge we build on what has gone before. Inevitably some of those theories will be superseded by new ones that explain the phenomenon better, but this doesn’t make those who came before us quacks and charlatans. Population based studies are helpful, but doctors and indeed chiropractors don’t treat populations they treat people, often with tricky problems. Most chiropractors I would suggest care for their patients and do their best for them using their skills and the evidence base. This will include their clinical experience as well as the research evidence.

  6. henbane said,

    October 18, 2009 at 2:08 am

    Dr Vincent, I have one quick question for you

    Libel action is expensive for both parties; why didn’t the BCA engage Singh on a basis of scientific evidence?

    If you believe there is good evidence for these practices, surely the evidence should be allowed speak for itself rather than seeking recourse with Judge Barmy in the most liberal libel jurisdiction in the world

  7. quasilobachevski said,

    October 18, 2009 at 2:36 am

    Dr Vincent,

    Your fine words notwithstanding, the main question is not whether chiropractic is effective according to some measures: clearly there are many people who go to chiropractors and are satisfied by the results.

    The main question is whether Singh was correct to say that there is “not a jot of evidence” that chiropractic is effective. Ben’s summary makes it pretty clear that Singh’s assertion was reasonable.

    All theory is a work in progress, as facts are confirmed so we are able to review our understanding, not everything is known.

    This sort of truism is the refuge of someone with no actual evidence to fall back on.

  8. Michael Grayer said,

    October 18, 2009 at 2:36 am

    Dr Vincent, nice attempt to worm your way through an argument using weasel words, but I’m afraid that is absolute twaddle.

    “Research evidence is not just RCT’s, neither is all research inquiry suitable for this quantitative paradigm.”
    True sometimes, but utterly irrelevant for the case of chiropractic. It looks like you try to back this assertion up using the rest of your comment, so we will soon see why this is a misleading claim.

    “However, because RCT’s are considered such compelling evidence there is a tendency to rely exclusively on them and for researchers to use the methodology even when to do so may not be appropriate.”
    False. For example, the link between smoking and lung cancer relies on not a single RCT. Why? Because to do so would mean conducting a trial where half of the participants would be made to start smoking. This of course would be unethical. It relies on other evidence such as cross-sectional studies, longitudinal studies and case-control studies though. If you have concerns about using RCTs then the next port of call is one of those and not qualitative studies or anecdotes.

    “RCT’s are suitable where the population is homogeneous and the treatment approach uniform. Chiropractors exhibit varying degrees of skill and make use of a number of treatment modalities making the design of RCT’s challenging.”
    Yes, but not only in those circumstances. Ever heard of “intention to treat” analysis? I think you’ll find that actually it’s not the design of RCT’s that’s challenging, it’s the design of RCT’s that’ll come up with a positive result that’s challenging. Why? Because a fair RCT won’t give you a positive result. There’s an obvious conclusion that can be drawn here.

    “Some procedures are similar to those employed by osteopaths and physiotherapists, so it is clearly not unreasonable to rely on evidence from these professions.”
    Yes it is, because chiropractic goes to great pains to differentiate itself from other treatment “modalities” (whatever that means). Therefore it is totally reasonable to expect chiropractic to come up with its own evidence base which doesn’t collapse when subjected to independent scrutiny, as the now infamous “plethora” did.

    “Cherry picking research is unhelpful…”
    No sh*t.

    “…but then so is the slavish reliance on RCT’s.”
    False. And utterly ridiculous to put reliance on RCT’s – the gold-standard of medical evidence – in the same boat as relying on cherry-picked studies.

    “We shouldn’t forget that Thalidomide was considered safe until a case series demonstrated its catastrophic effects.”
    Got any evidence for this claim? Even if you have, how is it relevant here?

    “The chiropractic profession does not have access to the vast sums of money available to the medical profession and so finds it very difficult to undertake large population based studies.”
    My understanding is that chiropractic treatment is quite an expensive thing to buy. I’m surprised that the chiropractic profession has not seen it as a top priority to put some money aside to pay for some proper trials that actually would satisfy the critics – not the usual anecdotal tripe that gets wheeled out again and again as though repeating biased research magically makes it any more valid.

    “Furthermore there is much to be said for outcome based research, cohort studies and qualitative research methodologies when looking into heterogeneous populations and skill based therapies.”
    Qualitative research?! Just what kind of qualitative study are you proposing? Conducting in-depth interviews with your mates? Qualitative studies certainly have their place – they would help us to understand why people turn to chiropractic for example – but that place is not here. And as for cohort studies, I think you’re right after a fashion but a) only if RCTs really aren’t possible and I disagree with your assertion that they are and b) I very much doubt that a properly conducted and analysed cohort study with adequate controls for bias and confounding would get you the positive results that you so crave – seemingly at whatever cost.

    “Manual therapy as practised by chiropractors, osteopaths and physiotherapists requires much more qualitative and quantitative research to be undertaken if we are to fully understand those aspects of treatment that are the most effective and the best way for such care to be delivered.”
    A wishy-washy water-treading conclusion, where you’ve tried (again) to lump chiropractic in together with osteopathy and physiotherapy. Pathetic.

  9. Martin said,

    October 18, 2009 at 4:33 am

    “All theory is a work in progress, as facts are confirmed so we are able to review our understanding, not everything is known.”

    This sounds like the mantra of the Homeopaths, which is a gross distortion of scientific progress through gradual improvements in our understanding of the universe.

    After all, when Newton said “If I have seen further it is only by standing on the shoulders of giants.” He never claimed that the giants were wrong; far from it.

  10. phayes said,

    October 18, 2009 at 5:18 am

    “claiming they can treat children’s colic, sleeping and feeding problems, ear infections, asthma and prolonged crying, by manipulation of the spine.”

    Implausible claims unaccompanied by sufficient evidence (of any kind) to reject the assumption that they are false. That’s quackery, Dr Vincent, and no amount of waffling and wriggling will make it otherwise.

  11. ayupmeduck said,

    October 18, 2009 at 9:59 am

    @ Dr Vincent

    “All theory is a work in progress, as facts are confirmed so we are able to review our understanding, not everything is known.”

    This rather falsely implies that most scientific theory is not very solid. Nobody is out there confirming the facts about the Theory of Evolution, the Theory of Relativity, Chaos Theory, Quantum Theory, etc., etc. A scientific theory is best thought of as a law, but more complex.

    “Inevitably some of those theories will be superseded by new ones that explain the phenomenon better.”

    No, not really. They might get added to, refined, but well held scientific theories are hardly ever overturned. Off the top of my head I can’t think of any well held scientific theory that has ever been overturned.

  12. Michael Gray said,

    October 18, 2009 at 11:02 am

    @ayupmeduck
    Devil’s advocate here.
    How about:
    * phlogiston
    * the luminiferous ether
    * the steady state model of the cosmos
    * the theory of the formation of mountains, prior to the grudging acceptance of plate tectonics
    * Freud’s bullshit theories
    * Eugenics
    * Lysenkoism

    … for starters?
    There are dozens more.
    And please don’t start playing the bagpipes! ;)

  13. Mojo said,

    October 18, 2009 at 12:15 pm

    @Dr Vincent:

    The chiropractic profession does not have access to the vast sums of money available to the medical profession and so finds it very difficult to undertake large population based studies.

    That is hardly an excuse for not considering the research that has already been carried out, such as the Olafsdottir et al. study, is it? As far as infantile colic, for example, is concerned it seems that it isn’t a question of lack of evidence, it’s that the research that has already been carried out points to the therapy being ineffective.

    As we refine our knowledge we build on what has gone before. Inevitably some of those theories will be superseded by new ones that explain the phenomenon better, but this doesn’t make those who came before us quacks and charlatans.

    What about those who come after us but still claim that the old theories have not been superseded?

  14. Mojo said,

    October 18, 2009 at 12:20 pm

    @Michael Gray:

    How many of those could be considered to be a “scientific theory” in the sense of being well supported by a large body of (or indeed all of the) evidence? I wouldn’t say that any of them was ever more than a hypothesis.

  15. ayupmeduck said,

    October 18, 2009 at 12:44 pm

    @Michael Gray

    As Mojo says, they are all pretty much ideas or hypothesis, and certainly were never well held scientific theories. They were theories in the sense of the word used by the layman. For example, when we talk about Freud, we commonly refer to *his* theories. When we talk about relativity we talk about *the* theory.

  16. jcmacc said,

    October 18, 2009 at 1:55 pm

    Dr Vincent says:

    “Population based studies are helpful, but doctors and indeed chiropractors don’t treat populations they treat people, often with tricky problems. ”

    So populations aren’t people? Really, what are populations made up of, trees?

    The importantance of population studies (epidemiology or outcome studies) over single accounts (case studies) is the difference between evidence based medicine and anecdote.

    Dr Vincent also says:

    “The chiropractic profession does not have access to the vast sums of money available to the medical profession and so finds it very difficult to undertake large population based studies”

    Hmm, I’ve never encountered a funding body called “the medical profession”, so this is bunkum. Chiros have enough money to fund their own professional bodies and associations who obviously have enough cash to bring libel suits to settle scientific arguments. Shame they don’t bother to fund scientific studies to solve scientific arguments.

  17. quasilobachevski said,

    October 18, 2009 at 5:30 pm

    ayupmeduck,

    …they are all pretty much ideas or hypothesis, and certainly were never well held scientific theories.

    How about the geocentric universe? The Ptolemaic model famously had to be refined again and again to bring it into line with observation. The result was supported by thousands of years of astronomical observations.

    Of course, if the BCA had anything like that wealth of data to support their claims then things would be very different!

  18. ayupmeduck said,

    October 18, 2009 at 6:34 pm

    @quasilobachevski

    “How about the geocentric universe?”

    Hmm, not bad. But you really had to go back 100’s of years to find that one, give me a modern example and I’d be more impressed ;-)

  19. quasilobachevski said,

    October 18, 2009 at 8:17 pm

    ayumpmeduck,

    give me a modern example and I’d be more impressed

    What are your objections to pre-plate-tectonics geology (wikipedia says it’s called “Geosyncline theory”)?

    I’m worried that you’re presenting scientific methodology as static. Of course, if you say that only theories that come from modern methodologies count, then there won’t be many overturned theories, as there won’t be many theories at all.

    Personally, I think Freudianism is a good example. It’s a massively influential theory, and like it or not, people at the time thought of it as science.

    I don’t mean to suggest that there should be room for Dr Vincent’s evasive nonsense. But methodologies do evolve. It will be interesting to see how String Theory pans out, as many of its critics’ points are essentially methodological.

  20. meccleshall said,

    October 18, 2009 at 9:37 pm

    The very existence of the robust, rigorous debate, and all the above discussion demonstrate exactly why the BCA’s libel action is so fundamentally wrong.

    The Libel court is absolutely not the arena to resort to in respect to ANY scientific argument – irrespective of the aggrieved party’s opinion.

    The BMJ, scientific journals, the press, blogs, websites, forums and other places of peer-reviewed academia, the media and public comment are the forums to discuss and advance human knowledge and understanding.

    Sod MPs expenses, the reform of British libel laws to remove the democratic car-crash that is the BCA’s action (as well as Trafigura, and a mountain of as-yet unrevealed super-injuncted issues) is the single most important democratic issue facing Britain today.

    Those who resort to the law to stifle their detractors’ analysis do not deserve to live within a democracy (and indeed, they are creating a situation where they don’t)…so PLEASE, keep posting, arguing and most importantly disagreeing on the chiropractic / alternative medicine debate – THIS is our precious democracy.

    Use it or lose it!

  21. ayupmeduck said,

    October 18, 2009 at 10:06 pm

    @quasilobachevski

    Probably we are splitting hairs here – as well as boring the hell out of the other readers. I guess where we are misunderstanding each other is illustrated by the fact that I don’t see Freuds ideas or String Theory (yet) as having the characteristics of proper scientific theories at all. But I see your point, and I guess it should not surprise us that Creationists can make hay by saying, “Evolution is only a theory”.

  22. pv said,

    October 18, 2009 at 10:11 pm

    Dr Vincent, I was under the impression that chiroquacks were passing themselves off as a branch of the medical profession. This is how they’ve been able to get away with medical fraud (claiming medical evidence where there is none) for so long.

    Incidentally, the history of chiropractic and the man who invented it should tell you something about the lack of evidence supporting your nice little earner. You also seem to be in some confusion about the meanings of “hypothesis” and “theory”, and what an experiment is.

  23. quasilobachevski said,

    October 18, 2009 at 11:00 pm

    ayupmeduck,

    You’re quite right – I do have a tendency to split hairs. :)

  24. Dr Aust said,

    October 19, 2009 at 12:18 am

    The (vanished?) Dr Vincent reminds me vaguely of my sparring partner “Cochrane Reviewer” from this thread a little while back over at Science Punk, where we had an extended debate about research into CAM therapies of varying plausibility

  25. Dr Aust said,

    October 19, 2009 at 12:18 am

    Arrgh – for some reason links keep getting stripped from my comments. Anyway, another try:

    scienceblogs.com/sciencepunk/2009/06/panicking_chiropractors_order.php

  26. Latrade said,

    October 19, 2009 at 9:26 am

    Is there not an argument that Chiropractors have no reputation, as such, to defame? I mean, if the Simpsons lampoon an industry/group, then you can infer that this is the general view of society, i.e. scpeticism and mistrust:

    en.wikipedia.org/wiki/Pokey_Mom

    Of course, the Simpsons would only be one of several bits of “popular” culture that have lampooned/questioned the integrity and validity of Chiropractors. See also Scrubs, West Wing and Seinfeld among others.

    Though funnily enough, Fox and HBO’s lawyers seem to have been missed on the defamations suits, but the episodes did spark some very angry newsletters.

  27. Wyatt Earp said,

    October 19, 2009 at 11:42 am

    [quote]Personally, I think Freudianism is a good example. It’s a massively influential theory, and like it or not, people at the time thought of it as science.[/quote]

    That’s simply not true. Questioning the scientific character of psychoanalysis is almost as old as psychoanalysis itself, starting with Karl Kraus and reaching its apotheosis with Karl Popper. And the theory existed alongside, and in tension with, other schools of thought within psychology: the first experimental pyschology lab was set up in about 1880, William James published a decade after that, and Pavlov began laying the foundations of Behaviourism at around the same time.

    There simply was never a time when Freudianism enjoyed the status of what you might call a “paradigm”.

    The geocentric theory is a better bet, not least because the later epicycle versions of it were actually a better match to observational data on planetary motion than was the simple, pre-Keplerian, circular-orbit Copernican heliocentric system. But the neatness with which the latter theory explained the phases of Venus was in the end persuasive.

    But this is complicated. The truth of the matter is that neither the heliocentric nor the geocentric model can claim to be “true”; each is simply a description in a different frame of reference. There exists, in other words, a correct geocentric description of the solar system–it’s just pretty complicated mathematically, whereas the heliocentric description is simpler. (Though in some ways not so simple as the [i]barycentric[/i] description, which is slightly different.)

    So the claim that the Earth is at the centre of the solar system isn’t of the same character as the claim that the Earth is flat: the latter is simply false, whereas the former just represents a suboptimal choice of coordinate system.

  28. Veronica said,

    October 19, 2009 at 1:17 pm

    Well we’ve got wonderfully off topic here, but to get back to chiropractic: it isn’t possible to do a randomised clinical trial to test the geocentric theory or any other geological theory. However, it could be done for chiropractic, and what Ben and other commentators on this thread seem to be saying is that to date there is no RCT that shows a positive result for any of the indications that the BCA are claiming. Bogus does seem to be a fair word, and it baffles me why alternative therpaies are not subject to the same level of proof as a new drug would be. There have to be serious questions about both the safety and the efficacy of these unproven treatments.

  29. Squander Two said,

    October 19, 2009 at 7:29 pm

    If I may jump right back up to comment number 4 from pv:

    > In science, as I understand it simply, when your hypothesis has been shown to be false, to be not confirmed by the best quality experiment, then it is discarded and you move on.

    That’s the ideal, yes. But, seriously, does anyone here really think that doctors do that? Science may, and medicine may, but scientists and doctors are as human as everyone else and doctors especially have a pronounced tendency to dig in their heels and stick their fingers in their ears when confronted with change.

    Which isn’t to excuse chiropractors or anyone else when they do the same. But these complaints would annoy me far less if they weren’t appended with the demonstrably risible “unlike the true scientists of conventional medicine, who would never do such a thing.” Aye, right.

    We migraine sufferers find it difficult to find doctors willing to treat us with anything better than a string of old wives’ tales. Most of them appear not even to have heard of Naramig. Chiropractice, meanwhile, has reduced my incidence of migraines from about one a week to maybe four a year. Bloody quacks.

    Michael Grayer,

    > chiropractic goes to great pains to differentiate itself from [osteopathy and physiotherapy].

    I once met a chiropractor who was fully qualified both as a chiropractor and a physiotherapist, and who therefore put both on her business cards. The BCA had no problem with this, but the CSP contacted her to pointedly tell her that they wouldn’t allow her to advertise as both and that they would withdraw her accreditation if she continued to do so. At least in that case, it wasn’t chiropractic that was going to great pains to differentiate itself from physiotherapy.

    I personally think Singh has a case to answer, as he accused a group of people of deliberate fraud — I wanted to believe him when I first read about this and I’ve repeatedly tried to read the offending sentence with any other spin, and it just doesn’t work. It’s an accusation of fraud — not just because of the word “bogus” but because of the whole sentence, especially following “respectable” with “and yet”, which clearly implies that what follows is not respectable. And I consider the way Singh and his supporters have gone on endlessly about the word “bogus” to be dishonest, as Eady made it clear in his ruling that he was looking at the whole sentence, not just that one word.

    I would also like to see scientific claims taken out of the jurisdiction of England’s appalling libel laws. But an accusation of fraud is not a scientific claim, so, even if the laws were fixed, this case would still not be excluded.

    Now, maybe Singh should win his case; maybe the accusation is warranted. The evidence presented above by Ben would certainly point in that direction. On balance, I hope he does. But his insistence that there shouldn’t even be a case in the first place is just plain wrong.

    On the other hand, a bunch of doctors should pool some money and sue the hell out of Jeni Barnett, on the same grounds: she made a few scientific claims, sure, but she also implied that doctors were deliberately and knowingly harming children for money.

  30. quasilobachevski said,

    October 19, 2009 at 8:33 pm

    Wyatt Earp,

    Thanks for your interesting response. I’m glad that someone took the time to spell out the important point that geocentricism is “wrong” in a different way than the claims of BCA are “wrong”.

    I hold my hands up and admit that I know very little about the history of psychoanalysis, though I’m not surprised to learn that Freud’s ideas have been contested for as long as they have existed. But I still think that Freudianism is an interesting example: it seems to me to be on the borders of “paradigmhood”.

  31. hilo said,

    October 19, 2009 at 8:40 pm

    Sad to see you being so unbalanced, defending your own creed (journalists) rather than the fairplay credo.

    The issue is that Mr. Singh said a bad thing and in a bad way. He was libelous. You did not cover that specific point in your article. A grave ommission.

    Turning to the things you did include in your article: Ernst is a master of lousy pseudo-science but he does have a knack of getting his name in the papers and in journals. How he gets through the peer review process and news editors would be a mystery if we had been born yesterday.

    RCT’s are not the only sort of evidence available, and off course research done by non-chiropractors is relevant to chiropractors – why do you think chiropractors test reflexes or measure blood pressure for example?! Osteopathic is relevant to chiropractic for example and vice-versa.

    Chiropractors are primary health care practitioners. Spinal manipulation or adjustments are the main but not the only method used to help patients, a range of interventions are called upon as needed. And chiropractors collaborate with other specialists and medical doctors as and when required by the patient’s best interests. Off course chiropractors treat patients with asthma . That does not mean that patients are told to lob their inhalers. But GP’s and sports teams for example, are happy, based on the evidence available, trials, case-studies, not to mention experience, to work with chiropractors.

    Chiropractors are active in research to support or refute what works. That it works is proven for a range of conditions (you ommitted to mention that in your article btw). But there are a couple of points you fail to raise, and possibly did not consider:
    1. Given that chiropractic does work for a range of conditions, why isn’t there more research on fine-tuning it and adapting chiropractic to a range of conditions? Why is there an effort to keep chiropractic in a small cul-de-sac? The answer is partly because older, legacy, monopolisitc incumbant professions and industries do not want to promote a new, innovate and what for them is probably an up-start profession. Not making this up, the OECD has published a report on competition in health which highlights obstacles to competion – the report mentions a case-study of a profession which won an antitrust case against the medical profession! www.oecd.org/dataoecd/7/55/35910986.pdf

    2. The second point is how innovation and new ideas come to the fore in clinical natural health care professions. In the medical world, new molecules and technologies spring from massive drug or equipment manufacturing company research budgets, often linked to university departments and grants. From there the ideas and new molecules get marketed and pushed out to the field practitioner. In chiropractic, most ideas and innovations come from the field practitioner, as case-studies, which evolve into new methods and techniques. Eventually the methods can be subjected to trials as well as other methods of evaluation. However throughout this process, most of the money to do the research is raised from the profession itself. There is no big industry to sponsor research into natural methods of healing.

    That should be enough to chew on. Bit more fairplay please.

  32. adamk said,

    October 19, 2009 at 9:49 pm

    How on earth does chiropractice help ear infections?!!

    Meccleshall said it – the libel court is not the arena for scientific debate.

    But , to be honest , you can understand why it happens. I’m sure most chiropracters are good caring people , who put alot into their work , believe in its benefits , and genuinely feel they are helping people. imagine then being told that some of your treatment is bogus , and as has been shown , really not having a jot of evidence to counter it.

    Robust rational debate is therefore out of the question (as there is no argument – sorry Dr vincent), and the libel courts seem an attractive option.

  33. Davdoodles said,

    October 20, 2009 at 12:49 am

    I agree with Sili’s point above.

    Accepting the Court’s definition of “bogus” – that the defamatory claim is that BCA KNOWS that its quackery is quackery – then own behavior condemns them:

    Ask yourself: IF they believe their stuff is effective, THEN WHY won’t they subject it to proper scientific scrutiny?

    Surely only someone who KNOWS it’s quackery would be reluctant to have it examined properly. If they were merely ignorant, or mistaken, why the refusal to test it?

  34. Hoffy said,

    October 20, 2009 at 11:17 am

    @ Dr Vincent:

    “The chiropractic profession does not have access to the vast sums of money available to the medical profession and so finds it very difficult to undertake large population based studies.”

    Horsefeathers, if I may say so, Dr Vincent.

    If we return to the case in point, the cure of childhood illnesses or conditions, you may have noticed that parents will pay ANYTHING to relieve their children of pain or illness. I know that chiropractic, as a private patient, is not cheap. The industry as a whole may not generate as much revenue as Big Pharma every year, but they felt they had enough of the folding stuff to risk high court action against Simon Singh.

    Think of how more wisely they might have invested that on RCT’s looking at the effectiveness of Chiropractic to cure childhood illnesses. Imagine if they found the “smoking gun” evidence that it did? It would put the profession on the soundest financial footing possible, with queues of parents waiting to subject their offspring to treatment. Buy to prey upon the vulnerability of desperate parents with no real evidence to back up your treatment is perhaps the cruelest confidence trick of all.

  35. Michael Grayer said,

    October 21, 2009 at 1:41 am

    @squander two
    “I once met a chiropractor who was fully qualified both as a chiropractor and a physiotherapist, and who therefore put both on her business cards. The BCA had no problem with this, but the CSP contacted her to pointedly tell her that they wouldn’t allow her to advertise as both and that they would withdraw her accreditation if she continued to do so. At least in that case, it wasn’t chiropractic that was going to great pains to differentiate itself from physiotherapy.”

    Interesting story, but I wouldn’t draw the same conclusion as you. In their indifference to having your acquaintance advertise both physiotherapy and chiropractic simultaneously on her business cards, I would infer that they suggest that chiropractic offers something above and beyond what physiotherapy does. This is what I meant by “at great pains to differentiate itself”. Apologies if that meaning was not clear.

    On the final point of suing Jeni Barnett, I don’t agree that that’s a good course of action. For one thing, it would be rather hypocritical to be condemning the use of law courts to conduct scientific discourse on the one hand, and on the other hand spending a lot of time and (taxpayers?) money pursuing legal action over scientific discourse on the other. Besides, I’m not even sure that “a bunch of doctors” qualify as an entity that can sue for libel. I’m not a lawyer though. You’d have to consult jackofkent.blogspot.com on that one.

  36. misterjohn said,

    October 21, 2009 at 10:53 am

    There’s a piece on the Sceptics blog today about chiropractic, which I’d recommend. I suspect the BCA wouldn’t like it.

    www.skeptic.com/eskeptic/09-10-21#shermerworks

    It refers to research proving that chiropractic can kill.

    As to Hilo’s point about why chiropractors take blood pressure, etc., I would suspect it’s for the same reason they wear white coats.

  37. HypnoSynthesis said,

    October 21, 2009 at 6:58 pm

    @ misterjohn
    In the consumer survey I mentioned in my earlier post, published in Arthur Klein’s Back Pain: What Really Works (2006), 11% of chiropractic patients the USA (n=422) responded that having chiropractic treatment “made me feel worse”, as did 14% in the UK sample (n=678).

    To be fair, 14% of people with back pain felt worse after visiting a faith healer as well, so maybe they’re misattributing naturally-occuring problems to the therapy.

  38. T said,

    October 21, 2009 at 9:32 pm

    I saw a dog getting acupunture on the one show on BBC 1 on Monday. This was followed up with a vet saying that she used acupuncture on pets as it was scientifically proven.

  39. mikewhit said,

    October 22, 2009 at 12:23 pm

    “a bunch of doctors” – I’m not even sure that “doctors” are something that naturally “bunch” … flowers, yes; a fist (bunch of fives), maybe; bananas, yep; electrons even, and plasma (see electronics books) yes, they/it can be bunched together.

    But doctors – no.

  40. Camp Freddie said,

    October 22, 2009 at 12:58 pm

    All quacks want to portray themselves as Einstein. Mavericks trying to overturn an establishment that clings to out-of-date theories.

    In fact, they are like Hoyle. They have out-of-date theories that they cling to despite the evidence that shows them to be false.

    Good studies have been performed. They show that chiropractic does not work. The BCA is aware of the studies yet ignores them. It’s claims about the effectiveness of chiropractic are therefore bogus (whether you define bogus as ‘false’ or as ‘wilfully deceitful’)

  41. quasilobachevski said,

    October 23, 2009 at 12:06 am

    hilo,

    Clearly, unlike Dr Vincent above, you have some facts at your fingertips. You assure us that Singh’s comments were “bad”. But, minus your ad hominem attack on Ernst, and your calls for more “balance”, you haven’t told us specifically why Singh was wrong (let alone libellous). Ben’s summary of the evidence regarding chiropractors’ treatment of “children’s colic, sleeping and feeding problems, ear infections, asthma and prolonged crying, by manipulation of the spine” seems pretty damning.

  42. Jessicathejourno said,

    October 23, 2009 at 11:45 am

    “Given that chiropractic does work for a range of conditions, why isn’t there more research on fine-tuning it and adapting chiropractic to a range of conditions? Why is there an effort to keep chiropractic in a small cul-de-sac? The answer is partly because older, legacy, monopolisitc incumbant professions and industries do not want to promote a new, innovate and what for them is probably an up-start profession.”

    Balls. First, that isn’t a given, and second, there isn’t more research on fine-tuning it and adapting it to a range of conditions because chiropractic professional associations fail to encourage such research in objectively measurable, reproducible ways. Hoffy (34) is quite right when he says that they have every advantage in doing so, so obviously so that the fact they haven’t is suspicious to the highest degree.

    There are doctors who do similar things to chiropractice in proper and accountable ways, they’re called osteopathic physicians, and if you want to chew on anything you can chew on the fact that chiropractic treatments are covered by more national and private insurance regimes than treatments from osteopathic physicians, despite osteopathic medicine actually having a bit of science, research and substance behind it.

    The story goes that several decades ago, GP lobbies in several countries decided they’d rather be in competition in the pertinent domains with something that doesn’t work all that well for that many things and isn’t universally taken seriously for pages and pages of good reasons (chiropractice) than outpatient specialist doctors who’d studied osteopathic medicine.

    So honestly, mop up the river you’ve been crying, if anything conventional medicine’s done nothing but favours to a profession which has done little to prove itself besides pulling a Roman Polanski in England’s libel courts.

  43. Colchicine said,

    October 23, 2009 at 5:37 pm

    There is evidence for the effectiveness of chiropractic in all levels of the hierarchy of evidence, including as RCTs:

    See:
    Meade et al., 1995
    Where “Chiropractic was found to be more effective, especially for those with “short current episodes, a history of back pain, and initially high [pain scale]” so the acute patient.
    Or:
    Triano et al., 1995
    Assendelft et al., 2003
    And even:
    Hurwitz et al., 2002
    Where in a “Randomized clinical trial (RCT) of patients in a managed care organization compared chiropractic care (with and without any of the following added: heat or cold therapy, ultrasound, electrical muscle stimulation) with conventional medical care (with and without physical therapy added). Participants (652) had acute, subacute, or chronic low back pain with or without leg pain. Back pain intensity and back-related disability were measured.” The results: “After six months of follow-up, the conventional medical care and chiropractic regimens were found to be comparably effective.”

    This can only mean that chiropractic care is as effective as conventional, allopathic, medical treatment. So, as a patient you have a choice; go to your GP and get some dugs or go to your chiropractor and get some hands on treatment. I know which I prefer.

  44. Colchicine said,

    October 23, 2009 at 5:50 pm

    Oh, and:

    “Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain
    A Randomized, Controlled Trial
    Jan Lucas Hoving, PT, PhD; Bart W. Koes, PhD; Henrica C.W. de Vet, PhD; Danielle A.W.M. van der Windt, PhD; Willem J.J. Assendelft, MD, PhD; Henk van Mameren, MD, PhD; Walter L.J.M. Devillé, MD, PhD; Jan J.M. Pool, PT; Rob J.P.M Scholten, MD, PhD; and Lex M. Bouter, PhD

    Results: At 7 weeks, the success rates were 68.3% for manual therapy, 50.8% for physical therapy, and 35.9% for continued care. Statistically significant differences in pain intensity with manual therapy compared with continued care or physical therapy ranged from 0.9 to 1.5 on a scale of 0 to 10. Disability scores also favored manual therapy, but the differences among groups were small. Manual therapy scored consistently better than the other two interventions on most outcome measures. Physical therapy scored better than continued care on some outcome measures, but the differences were not statistically significant.
    Conclusion: In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner”

    So, I think its reasonable for any chiropractor, especially mine, to say he can help me and if I choose to refuse the drugs and accept his treatment then that is my choice and I am happy to have it available to me.

  45. Squander Two said,

    October 23, 2009 at 9:24 pm

    Michael Grayer,

    > For one thing, it would be rather hypocritical to be condemning the use of law courts to conduct scientific discourse on the one hand, and on the other hand spending a lot of time and (taxpayers?) money pursuing legal action over scientific discourse on the other.

    My point is that it’s not scientific discourse. Her claim that MRI doesn’t work is a scientific claim. Her claim that doctors secretly know that MRI doesn’t work yet still use it in the full knowledge that it will harm children isn’t. If you’re a doctor who administers the MRI to children, that claim is clearly actionable and will harm your professional reputation. Hell, such claims demonstrably have harmed doctors’ professional reputations. So leave the science to proper debate and sue anyone who makes such appalling libellous claims, because such claims aren’t about science; they’re about character. In my opinion, scientists’ insistence on treating all such claims as scientific is not doing science a lot of good right now.

    I had suggested that more than one doctor (and I must apologise profusely for using the common English term “bunch” to describe more than one person; had no idea anyone would get so riled by that) might want to pool their resources for such an action simply for financial reasons. On second thoughts, though, it was an unnecessary suggestion, as your average GP makes enough to fight a High-Court libel battle about every ten minutes.

    Jessicathejourno,

    > The story goes that several decades ago, GP lobbies in several countries decided they’d rather be in competition in the pertinent domains with something that doesn’t work all that well for that many things and isn’t universally taken seriously for pages and pages of good reasons (chiropractice) than outpatient specialist doctors who’d studied osteopathic medicine.

    So what you’re saying is that, faced with good science with good evidence, the medical profession threw a hissy fit and called the practitioners “quacks” in order to protect their own income. And this is evidence of why we should trust the medical profession whenever they call anyone a “quack” and accuse them of lying for profit. Good to know.

    You are of course quite right. For all that you’re wheeling out osteopathy now as an example of real evidence-based science so that you can compare it favourably to chiropractice, the usual attitude of doctors towards osteopathy is that it’s quackery.

    As I’m always saying, I love the idea of evidence-based medicine, and I’ll happily go get some if the medical profession ever start providing it. Their record on that front, however, is inconsistent and unreliable. I’m not talking about published papers or official knowledge; I’m talking about what a patient actually gets from a doctor.

    Colchicine,

    > So, as a patient you have a choice; go to your GP and get some dugs or go to your chiropractor and get some hands on treatment.

    With the caveat that, for back problems, as a rule, the drugs will generally be painkillers and hence will only treat the symptoms. Chiropractors can fix the root cause.

    Now, in my case, my chiropractor gave me exercises to do to stretch my hamstrings, which addressed the root cause of my back pain (so bad I couldn’t get up one morning), and I’m sure plenty of people here would leap on that gleefully to point out that the exercises weren’t officially specifically uniquely chiropractic and were in fact physio being given to me by a chiropractor. Yup, absolutely, and I think my then chiropractor would agree. I fail to see why this is a problem. As Hilo says, they’re primary care practitioners. They use a number of different treatments, depending on what’s necessary. So do doctors, as it happens. “But some of the stuff they do is actually physiotherapy!” is as damning of chiropractors as “But that’s not a drug!” is of the GP who’s just put you down for an MRI scan.

    And my chiropractor, whatever combination of treatments he used, was a lot more use than my evidence-based conventional-medicine GP, who didn’t even look at my back and gave me a prescription for ibuprofen, allowing me the opportunity to pay six quid for the same pack of pills that, without the prescription, would have cost me less than twenty P. These are the real-life comparisons patients make.

    I’d like to add another observation about my experience with chiropractors. My back is currently fine, so I go see my chiropractor about once or twice a year. She never suggests that I need to see her more. My first chiropractor scaled down the treatment rapidly as my condition improved, until I was seeing him, again, about once or twice a year. The chiropractor who claimed to manipulate my step-sister’s cranial bones in order to cure her dyslexia did so in just one session, with no repeat visits ever. Putting aside for one moment whether it works or not, if I were a con-man, I’d be encouraging people to give me more money, not less.

    Apologies for the huge bloody great comment. I’ll try to keep it shorter in future.

  46. allshallbewell said,

    October 23, 2009 at 9:44 pm

    Colchicine:

    “See: Meade et al., 1995 etc.”

    If you’re giving references to articles, and you really want people to read them, a full citation is useful.

  47. Jessicathejourno said,

    October 24, 2009 at 7:51 am

    “So what you’re saying is that, faced with good science with good evidence, the medical profession threw a hissy fit and called the practitioners “quacks” in order to protect their own income. And this is evidence of why we should trust the medical profession whenever they call anyone a “quack” and accuse them of lying for profit. Good to know”

    Once more, balls. First, that wasn’t what I was saying at all; how you thought that was evidence of why we should trust the medical profession et cetera is beyond me, when what I was talking about is why we shouldn’t trust chiropractice.

    Second, that ‘story’ is just that, a story, unsubstantiated by any historical evidence I’ve seen, and something I’ve only heard from midwives and practitioners of osteopathic medicine. But I give it some small credence, because we do indeed live in a world where something with so little substantiation behind it (chiropractice) is covered by more insurance regimes than something with much more substantiation (osteopathic medicine). As evidenced by the BCA ‘borrowing’ evidence of effectiveness from osteopathic medicine research.

    Of course, based on that present outcome, there’s a very good chance chiropractice’s accessibility, insurance wise, has very little to do with pissy doctors and a great deal to do with effective lobbying from chiropractic professional associations.

    So if these people are capable of lobbying national and private insurance bodies so effectively, and if they’re capable of coming together to pull a Roman Polanski in Britain’s libel courts on someone who was, after all, only blathering in accordance with the evidence (or lack thereof), and if they can do absolutely beautiful things like cure dyslexia by re-aligning cranial bones in one session, and in the knowledge that you’re quite right – GPs are often dismissive and extremely unhelpful when it comes to chronic problems, and if that really changed, so much ‘bad science’ would disappear overnight that Ben would need to look for a new column – then why the hell haven’t they been able to scrape the gumption together to systematically document their cures?

    The only answer that presents itself, especially after reading all the great personal experiences here, is that not all chiropractors are con-men, but enough of them are that their professional associations just don’t dare take those sorts of measurements, especially when they haven’t needed to in their bid to wheedle their way under insurance coverage.

  48. Squander Two said,

    October 25, 2009 at 8:16 pm

    > that ’story’ is just that, a story, unsubstantiated by any historical evidence I’ve seen

    Well, please don’t complain at me for mentioning it, then, when it was you who brought it up.

    Honestly, some people.

    By the way, a lot of people have used Britain’s libel laws over the years. I wonder at your repeated use of Roman Polanski’s name. It’s like you’re trying to get Google to associate his name with chiropractice or something. Which, considering that the libel case isn’t exactly the most prominent immoral thing he’s famous for, might be considered just a tad unfair on chiropractors.

  49. jazz_the_cat said,

    October 26, 2009 at 2:44 pm

    reading the evidence about dimethicone & chiropractice. Sounds to me like dimethicone doesn’t work very well, if the placebo control works better.

    cheers

  50. Colchicine said,

    October 26, 2009 at 7:08 pm

    Allshallbewell,

    As you request:

    Meade TW, Dyer S et al 1990. Low Back Pain of Mechanical Origin. Randomised Comparison of Chiropractic and Hospital Outpatient Treatment, BMJ 300: 1431-37;

    and the follow up study:

    Meade T W, Dyer S et al 1995. Randomised Comparison of Chiropractic and Hospital Outpatients Management for Low Back Pain Results from Extended Follow Up, BMJ 311: 349-351.

  51. Colchicine said,

    October 26, 2009 at 7:28 pm

    Jessicathejourno,

    You appear to bestow near mythical healing powers on the allopathic osteopaths. This seems over zealous considering they perform the same examinations as other, lesser, osteopaths and chiropractors and treat in a surprisingly similar manner with similar success rates (so much so I suspect you couldn’t tell the difference). Do you happen to know one very well?

    Also, it is definitely considered good research practice to draw widely from similar fields – and you should be worried if this:
    “As evidenced by the BCA ‘borrowing’ evidence of effectiveness from osteopathic medicine research.” was not happening, especially as they are doing pretty much the same things, even the Medical Osteopaths.

    I think you are wrong in your insinuation that there is no research going on in the chiropractic world – any proof? I’d like to see the numbers of papers produced by chiros against those produced by osteopaths.

  52. Bloodvassal said,

    October 26, 2009 at 11:45 pm

    >Meade TW, Dyer S et al 1990. Low Back Pain of >Mechanical Origin. Randomised Comparison of >Chiropractic and Hospital Outpatient Treatment, BMJ >300: 1431-37;
    >
    >and the follow up study:
    >
    >Meade T W, Dyer S et al 1995. Randomised Comparison of >Chiropractic and Hospital Outpatients Management for >Low Back Pain Results from Extended Follow Up, BMJ 311: >349->351.

    #50 I don’t know much about chiropractic or for that matter physiotherapy but I do know a wee bit about experimental layout it seems to me that this wasn’t a terribly well balanced study on a number of levels.

    The first appears to be that there is absolutely no control for exactly what therapy was given to any individual patient. Indeed, there is no mention of what exact therapy was given. How can we compare?

    Second, having sat in NHS waiting rooms and been treated in an NHS ward and as an outpatient, the biggest identifiable experimental modifier appears to be where the therapy took place. That is, a private chiropracter’s office or an NHS hospital room. This study isn’t truly a comparison of therapy, which is the whole point of your post, it’s a comparison of public versus private.

    There also appears to be nearly a 25% difference numbers of long term questionaire returns, with the highest number coming from those receiving chiropractic. And the bias further creeps in with the fact that many of the patients being given chiropractic were previously users of chiropractic services. Indeed the authors themselves say:
    “Those referred by chiropractors consistently derived more benefit from chiropractic than those referred by hospitals.”

    Already predisposed to thinking that it benefits them these patients confirm their belief in this study.. confirm their belief… hmm belief… yes, confirmed their faith in the therapy, in their healing.. their faith in their healing… faith healing… wow.

    Ultimately I think that the authors themselves sum it up nicely in their own Key Message from the paper. Their conclusion is that treatment in a chiropractic office is superior to treatment in a hospital but why? Authors’ Key message:

    “Chiropractic seems to be more effective than hospital management, possibly because more treatments are spread over longer time periods”

    They see the practitioner more. Private office nicer than cold hospital, chiropractic practitioner has more time to talk than physiotherapist. And this is the big evidence of the benefits of chiropractic as opposed to conventional treatment? Here’s a small unsubstantiated, unreferrenced, unscientific comment… repeat that study with chiropractic in an NHS hospital, or physiotherapy in a private clinic and see those statistical differences fall away.

  53. Bloodvassal said,

    October 27, 2009 at 12:17 am

    Oh Dear…. Triano et al. a study of patients actively seeking chiropractic then comparing those who got it (HVLA in the paper) with those who essentially didn’t (HVLF), and finally those who were shown a powerpoint presentation which told them to sit up straighter. Again.. those who went there expecting to receive chiropratic and got it, felt better than those who didn’t.

    You know I really didn’t have an opinion about chiropratic until I read these papers.

  54. Bloodvassal said,

    October 27, 2009 at 12:28 am

    In a new segment called Seriously. Seriously.. Assendelft et al 2003. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies.

    Independent and blinded meta-analysis no less.

    Authors conclusion… nicely summarised in the Abstract:

    CONCLUSIONS: There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.

    Does this really help a pro-chiropractic argument? Seriously? SERIOUSLY?

    I was only going to post a sentence when I first read the blog but dude… seriously?

  55. mikewhit said,

    October 27, 2009 at 1:42 pm

    “conventional, allopathic, medical treatment.”

    Isn’t “allopathic” (different feeling) used in opposition to “homoeopathic” (same feeling) – in which case what’s it doing in a discussion about rubbing people’s backs ?

  56. mikewhit said,

    October 27, 2009 at 1:46 pm

    “if anything conventional medicine’s done nothing but favours to a profession which has done little to prove itself besides pulling a Roman Polanski in England’s libel courts.”

    I didn’t know that the lady who was subject to “lymphatic stimulation” was under age …

  57. Dr Aust said,

    October 27, 2009 at 11:10 pm

    Nice exposition of the possible confounding effects, Bloodvassal.

    Anyone still in doubt as to the resounding feebleness of the research that chiropractors have attested to support their therapeutic claims should go back to Ben’s post from 29th July, where he links to many of the bloggers who “deconstructed” the BCA’s “plethora of evidence” (i.e., the best published research they could come up with for chiropractic for children’s ailments, which wasn’t much):

    www.badscience.net/2009/07/we-are-more-possible-than-you-can-powerfully-imagine/

    – the 7th para down is the one with the links.

    Links to many of the same blogs, and some others, can also be found at the Lay Scientist site:

    www.layscience.net/node/598

    Re chiropractic for lower back pain, the only indication for which it has any real plausibility, there is not much evidence there either. Some studies show it working about as well as other things, but the key point is that NONE of the interventions or treatments work well. (Note that that includes the conventional stuff). Prof David Colquhoun has written about this a lot. Since chiropractic is expensive, and is based upon a “business model” of convincing you you have to keep coming back for more “adjustment”, it would not be the option of choice for back problems, IMHO. If you want back manipulation, physiotherapy is more accessible, certainly via the NHS in the UK, and comes free of all the chiropractic mumbo-jumbo. For a GP view saying something similar see:

    northerndoctor.com/2009/07/03/chiropractic-and-ethics-in-the-bjgp/

    Re the cost of chiropractic, my other half, who is a conventional doctor and sees a lot of patients with back pain, has come across patients forking over something like a third of their monthly pay to be “adjusted” weekly by a chiropractor. I think personally that we in the UK are very fortunate to have escaped the US situation where chiropractors are able to present themselves as “primary healthcare professionals”.

    Finally, there is a good summary regarding chiropractic claims in general at Lay Scientist here:

    www.layscience.net/node/566

    PS Sorry not to embed the links to make this look nicer, but it hasn’t been working recently.

  58. Squander Two said,

    October 28, 2009 at 8:35 pm

    Dr Aust,

    > Since chiropractic is expensive, and is based upon a “business model” of convincing you you have to keep coming back for more “adjustment” …

    As I mentioned above, I’ve yet to come across a chiropractor who uses that business model. Every one I’ve seen and every one anyone I know has seen has taken the attitude “You’re cured! Yay! You don’t need me any more! Brilliant!” I’m sure some of them are using that business model, but to say that the entire field is based on it is demonstrably wrong.

    I wouldn’t call it expensive, either. The average GP’s salary is now over £100k, so a quick back-of-the-envelope calculation shows that GPs are charging at least £50 an hour. Some are making more like £250k, which comes to about £120 an hour. And of course your GP won’t provide any back-pain treatment; they’ll either prescribe you drugs which cost money or refer you to another medic who’ll cost money. Chiropractors are about £30 per 20-minute session. So not cheap, but certainly not expensive, either. Even if you think they provide nothing more than glorified massage, their rates still compare favourably to masseurs’.

  59. mikewhit said,

    October 29, 2009 at 3:24 pm

    “The average GP’s salary is now over £100k”:

    www.nhscareers.nhs.uk/details/Default.aspx?Id=553
    “Many general practitioners (GPs) are self employed and hold contracts … Salaried GPs employed directly by PCTs earn between £53,249 to 80,354, dependent on, among other factors, length of service and experience.”

    www.mysalary.co.uk/average-salary/Gp_1231
    “The average salary for a Gp in the UK is: £63,688″

  60. Dr Aust said,

    October 30, 2009 at 4:49 pm

    MikeWhit has already made the point about GP’s salaries. The higher figures are for particular sub-classes of GP partners, who effectively run businesses as well as being GPs. (They do this, now on “payment by results”, because the Govt insisted that this “incentivised” system was how they should do it, BTW).

    Salaried GPs, of whom there are more and more, earn far less, though no-one is saying they are poorly paid.

    A quick look around reveals private GP rates in the UK run around £ 50-100 for a 15 min consultation, and £ 25 for 5 min on the phone. Of course, the NHS does not charge you for anything, including phone calls and home visits (if needed), let alone dunning you for more money if you over-run your slot.

    So… even if you assume top of range salaried GP (£ 80K), and 37.5 hrs /wk (which I predict will never be that little, as surgeries always overrun, and they do home visits, phone calls, paperwork etc etc.), and 48 working wks/yr, you can back-of-the-envelope to £ 50-60 / hr.

    The private sector charges four times that, to see a doctor you may not know from Adam and who has no B/G info on you.

    Incidentally, the system of GPs as gatekeepers to secondary (hospital) care will work better (better diagnosis, less unnecessary referral) when the GPs are more skilled and more experienced. Which probably also means better paid in any business model.

    It is the pretty much universal verdict of academic health economists who have studied UK general practice that it represents one of the greatest healthcare bargains you are ever likely to get offered. In 2004 (admittedly a while back) the costs to the taxpayer were estimated as between £ 12 and £ 55 per patient per year (v. young, or old and sick, patients cost more).

    fampra.oxfordjournals.org/cgi/content/abstract/22/3/317

    I’m glad Squander Two (Comment 58) has found some honest chiropractors. Unfortunately, they are not all like that. My other half saw a patient recently who had, for several months, been forking over a third of her monthly take-home pay to a chiropractor for weekly “adjustments” to help with lower back problems. (It wasn’t helping.) When the patient told the chiropractor she had a non-spine related problem he helpfully told her he could sort that out too. Assuming she could paid for the extra sessions, of course.

  61. Dr Aust said,

    October 30, 2009 at 6:00 pm

    PS Oops – sorry, same anecdote again, didn’t re-read my previous post. My bad.

    Much more of this story-telling and I will have to set up in business as an Alternative Practitioner.

  62. mikewhit said,

    November 2, 2009 at 1:29 pm

    “My bad.”

    Your bad what ?
    … bad back ?!
    ;-)

  63. Squander Two said,

    November 2, 2009 at 8:08 pm

    Just to be clear, I wasn’t complaining that GPs earn too much. I was just comparing. If you want to claim that chiropractice is expensive, “Compared to what?” seems like a reasonable question. I was unaware that there were two lots of figures for different types of GPs. However, using your lower figures, and taking into account that, as I said, GPs’ costs are only the start of the cost of a medical treatment, I still don’t think chiropractors are expensive.

    Not sure why you’re getting into the whole NHS-versus-private thing, but, since you are…

    > The private sector charges four times that, to see a doctor you may not know from Adam and who has no B/G info on you.

    Eh? Surely, whether I’m on the NHS or going private, I can opt to see a doctor who’s never heard of me. If I want to go private, I can get a private GP and see that same private GP every time, until they know me. If I move from the NHS to a private GP, I can have my records transferred. I can move from a private GP to an NHS GP, and thus end up seeing someone who doesn’t know me from Adam and doesn’t have any of my records unless they get hold of my records. Lots of doctors work both on the NHS and privately, so I even have the option of seeing exactly the same doctor via the two different payment mechanisms. That doctor will not magically forget all about me if I start seeing him privately. I don’t think your assertion that NHS GPs know their patients whilst private ones don’t holds much water.

    > Of course, the NHS does not charge you for anything, including phone calls and home visits (if needed)

    People in this thread are complaining that chiropractice is covered by some health insurance firms, so it makes as much sense to compare it to private as to the NHS. Who’s picking up the tab isn’t the issue.

    Secondly, the NHS charge a very large amount of money. The fact that I get charged the money before it reaches my payslip rather than after it reaches my bank account doesn’t mean it doesn’t exist.

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  65. fiolondon said,

    December 8, 2009 at 1:04 pm

    Hi

    I am a bit scared of some of the people on this forum – someone earlier asked what evidence there was that Thalidomide was harmful!!!! No-one bothered to mention so I slightly wonder whether it is worth me making the following points……

    Way up the top, Dr Vincent said
    “The chiropractic profession does not have access to the vast sums of money available to the medical profession and so finds it very difficult to undertake large population based studies.”

    Which seems to have been roundly dismissed by all! At the risk of being lambasted I thought it was an interesting point.

    Mainstream medical research is sponsored by pharmaceutical and surgical manufacturers, government and big name charities. Privately sponsored research actually pays people to participate and studies are replicated to get the right answer and cherry picked for publication. (My husband used to be a pharmaceutical rep – apologies for the use of an anecdote rather than a referenced RCT there folks.)

    Anyway, in contrast, I think that Chiropracters are self employed sole traders working on their own. They might each see a maximum of 70 patients a week if they were fully booked and never ate lunch. If one dedicated individual decided to go for it and get a sample of say, 3000 people – which does not sound like a lot – it would take an about a year’s worth of appointments. To do a full RCT the treatment would have to be offered free of charge. That adds up to an individual practicioner going for a year without pay (before anyone suggests spreading it out over a longer period it is still the same amount!). What individual is going to be able to afford to do that?

    I’d say Dr Vincent has a point.
    F

    . So to get enough data they would presumably have to sacrifice their personal income over quite a period.

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