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.

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.

Your bad what ?
… bad back ?!

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

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).

http://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.

- http://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.”

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

> 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’.

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):

http://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:

http://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:

http://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:

http://www.layscience.net/node/566

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

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

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 ?

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?

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

#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.

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.

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.

cheers

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.

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.

“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.