Just when you think the British Chiropractic Association might have learnt that every time it offers a public response it tends to blow up in it’s face and that it might be wiser to stay silent a new article by Richard Brown, the BCA vice president, pops up. This time round his response appears in the British Medical Journal and purports to be about ‘clarifying the issues’ surrounding the BCA’s case and the evidence for it’s claims.

And the result?

In the same issue as Brown’s article there is also a response written by Edzard Ernst. Ernst’s response is a short but thorough assessment of the quality and relevance of all of the “substantial evidence” which Brown cites in his article. He shows that every single reference cited by Brown is either irrelevant or of very poor quality. Ernst’s conclusion is that “the association’s evidence is neither complete nor… substantial”. This conclusion is echoed by Fiona Godlee, the editor of the BMJ, who writes that “[Ernst’s] demolition of the 18 references is, to my mind, complete”, proceeds to recommend that all readers of the BMJ should be “signed up to organised skepticism” and finishes by criticising the intrusion of legal cases into what should be scientific debates.

So once again it’s another PR disaster for the BCA as now, thanks to Richard Brown’s article and its terrible citations, one of the UK’s premier medical journals joins the chorus of critical voices directed at the BCA and its libel case. And not only that but it is urging its readers to follow suit! But before anyone starts to feel sorry for poor old Richard let’s take a more detailed look at what he actually said…

I would strongly recommend first reading Brown’s article sans commentary and then reading Edzard Ernst’s response in the same issue of the BMJ before reading my analysis of Brown’s article . Both can be accessed for free online, both are short reads (about a page each) and both are well written. More importantly, for my purposes, they put the comments/analysis I am about to offer, which will focus primarily on Brown’s rhetoric, into context. Now, without further adieu…

It is quite remarkable that scientists should expect themselves to become exempted from the laws of the land for publishing defamatory comments, be they about an individual or an organisation. Having mustered an army of supporters, including Evan Harris, Simon Singh has redefined the battle as one of free speech and the stifling of scientific debate. It is nothing of the sort.

Thus begins Richard’s article. Here I would draw attention to the overwhelming amount of rhetoric already on display! Richard is attempting to portray ‘scientists’ as elitists who consider themselves above the law and who are willing to distort and redefine debates to try and avoid straightforward legal repercussions. This is certainly a creative reinterpretation of the situation but it is by no means accurate.

British libel laws are widely recognised as fundamentally flawed which is why states in America have begun to make laws to protect their citizens from British libel rulings and why dubious figures from all over the world make a bee line to British courts when they want to bring a libel case against a critic.

Richard seems to be suggesting that Simon and the supporters of his case are focusing on the need to reform libel laws in order to try and let Simon weasel out of a legitimate libel case but what this ignores is that any reforms that come about will undoubtedly only come into effect after Simon’s case is long finished.

Casting a science writer who is daring to defend himself against a libel action as a nefarious villain scheming to overcome a just law is a rather transparent fiction that anyone who looks into the case will immediately see through but it is a nice way to try and rebrand the BCA’s actions. It is also worth noting is that for someone who professes to be so concerned with libel and reputation Richard certainly doesn’t seem to feel the need to pull any punches against those he disagrees with.

The British Chiropractic Association (BCA) neither wished nor intended this matter to end up in the courtroom. When Dr Singh went on the offensive against the BCA and spoke of it promoting bogus treatments that had “not a jot” of evidence to support them, it was entirely understandable that the BCA should seek to have what were untrue and defamatory comments withdrawn in order to protect its reputation.

Jack of Kent has already commented on this but to repeat anyone who brings a legal case should be prepared for it to end up in court. Essentially what Richard is admitting here is that the BCA originally brought the legal case as a threat in order to try and get Simon to retract his statements. That is exactly the kind of misuse of libel law that the campaigns to reform libel laws are seeking to challenge. As far as bringing the case being ‘the logical step’ to protect the BCA’s reputation, I cannot help but think that perhaps the first logical step to protect the BCA’s reputation would have been to publish a rebuttal in the Guardian. The BCA was offered this option and refused. Instead, it chose to bring a libel case which has resulted in the BCA and the chiropractic profession tarnishing its reputation almost beyond repair in the blogs, in the mainstream media and now in the medical journals. If reputation was the primary concern then ‘the logical step’ has backfired triumphantly.

It sought from Dr Singh a retraction of the allegations along with a public apology. Scientific debate could then have continued away from the law courts. However, despite receiving invitations to retract and apologise, Dr Singh refused to do either.

Worth remembering is that the BCA “sought a retraction” via legal threats and was so interested in continuing the scientific debate “away from the courts” that it turned down all offers to write a reply or for Simon to write another article clarifying his position and then waited for over a year before it published it’s less than impressive ‘plethora of evidence’. More details about the offers the BCA turned down can be found here.

There is in fact substantial evidence for the BCA to have made claims that chiropractic can help various childhood conditions.

There really isn’t. Richard goes on to recite the completely discredited ‘plethora’ of evidence that has already been exhaustively demonstrated to consist entirely of deeply, deeply flawed studies and entirely irrelevant material. Ernst takes it all apart again anyway but it is telling that Richard is still citing numerous studies that refer to osteopathy despite the fact that it has already been pointed out numerous times already that osteopathy is not the same thing as chiropractic.

Sadly, Dr Singh now argues for what he wished he had said, rather than what he did say. As a diversion from his defamatory comments, he has mounted a case for free speech and reform of the libel laws. The BCA fully supports free speech. However, with this fundamental right comes responsibility, and as a science journalist Dr Singh should not have published materials which he was fully aware would damage the BCA’s reputation.

If anyone thinks Simon is now arguing for something different than what he originally ‘said’ I invite them to re-read his original article. He criticised the BCA’s promotion of chiropractic treatments for a range of childhood ailments for which there is no evidence that they can effectively treat. To me this seems to be the position he is still defending.

As far as Simon not publishing his article because it would “damage the BCA’s reputation”, I was not aware that this was a journalistic requirement. If the BCA’s own actions damage it’s credibility then it is not Simon’s fault for reporting on them, nor should he be prevented from commenting or criticising them.

Suggesting that free speech is only a ‘fundamental right’ if it does no damage to anyone’s reputation is not being a supporter of free speech. Sometimes individuals and organisations do things that damage their reputation and journalists should be free to write about such things. We should hold journalists accountable for what they write but in this particular case the BCA did promote what Simon said (look at the happy families leaflet) so that is not really an issue.

Chiropractors, as regulated healthcare professionals, should be accountable for their actions. They are subject to a code of practice that exists to protect the public and uphold standards of care.

Agreed and one would hope that Richard therefore supports the recent complaints against chiropractors who break the code of practice. I wonder if he does?

They are also bound to practise evidence based medicine, which, like that of their medical colleagues, comprises the best available evidence from research, the preferences of the patient, and the expertise of practitioners (including the chiropractor him or herself).

If the “best available evidence” is of concern one has to wonder why the BCA’s plethora and the evidence Richard cites in the article include so many appalling and irrelevant studies but fail to refer to larger and better controlled studies with negative results. Instead what I think Richard is actually trying to imply without directly saying so is that research evidence is not all that important to evidence based medicine and in fact if the patient and the chiropractor believe that a treatment works and any studies (regardless of quality) say the same thing then that should be enough to constitute a treatment being ‘evidence based medicine’. That’s a fairly typical position for an alternative medicine advocate but it is still a forehead slapping affair…

To reduce the definition of evidence to only randomised controlled trials not only is impossible but would exclude many medical interventions performed in general practice each day.

No-one is suggesting that ONLY randomised controlled trials count as evidence. What people are suggesting that the results from better controlled trials should be considered as more compelling than the results from poorly controlled trials and that if the only evidence of efficacy is from small poorly controlled trials then there is not enough evidence to make medical claims. Why including a placebo group should be controversial is beyond me if chiropractors really believe their treatments are effective.

Contrary to the suggestion that chiropractic is purely synonymous with spinal manipulation, it is a primary healthcare profession that employs a range of interventions that benefit tens of thousands of patients each day.

Suggestions supported by sources like the General Chiropractic Council who produced a survey of attitudes and practices of the chiropractic profession in 2004. This survey reports that 99.41% of chiropractors indicated they use chiropractic adjustments to treat patients with 89.81% saying they offered it in 81-100% of cases. It also shows that 97.42% of chiropractors think they can treat back problems whereas with other non-back related problems the percentage drops significantly (with asthma it is 57.49% and colic 63.11%). The other major treatments mentioned included therapeutic exercise, advice on daily life, nutrition, lifestyle and ‘psychosocial’ which do not really seem any more suitable for treating things like ear infections and colic than spinal manipulations.

The BCA is fully supportive of chiropractic research and indeed gives tens of thousands of pounds every year to support research initiatives throughout the UK. It is preposterous to suggest that the BCA seeks to either “stifle scientific debate” or engage in “chilling” science writers from expressing their views.

Tens of thousands is much less than the cost of the libel case and the fact that the BCA provides chiropractors funding to produce the kind of poor studies it then uses to support its claims says absolutely nothing about their commitment to scientific debate. The fact that they sued a science writer for an article he wrote about chiropractic treatments lacking evidence says much more. Their willingness to threaten legal action also suggests that this may not be the BCA’s first foray into the legal intimidation arena, though, at the minute, that remains speculation as I’m not aware of any previous cases/threats. Might be something worth looking into…

The inclusion of spinal manipulation in the guidelines on low back pain recently published by the National Institute for Health and Clinical Excellence was founded on peer reviewed, published research evidence demonstrating its efficacy. The risks of spinal manipulation have been researched, and two comprehensive studies in Spine demonstrated it to be far safer as an intervention than commonly prescribed medical interventions used for similar ailments.

The NICE guidelines seem to have been unduly influenced by certain pro-CAM advocates that had more influence than they should over the guidelines. More details and further links can be found here:

• David Colquhoun’s detailed coverage (part 1, part 2, part 3).
• Criticism in the BMJ.
• Some more links to be added shortly.

The Spine studies have also been shown to be rather less persuasive than Richard Brown would have us believe. More details are here:

• Mark Crislip gives a thorough analysis of one of the studies on science based medicine.
• Harriet Hall discusses chiropractic reaction to safety concerns and discusses the Spine studies.

The indignance is palpable that a group of complementary health practitioners should dare to challenge the scientific establishment.

Ah the trusty old jab at the “scientific establishment” with its “esteemed figures” who are indignant when anything new challenges their established paradigms (sigh…). The “indignance” is because complementary (Note: not alternative!) health practitioners want to be considered as a valid part of mainstream medicine and yet they want entirely different standards applied to their claims. Complementary/ Alternative medicine practitioners typically make claims that are not warranted by the evidence and then demand that a different (lower) standard of evidence should be applied to their treatments. The BCA and Richard illustrate this perfectly with their terrible citations. Still nice use of David vs. Goliath and Conservative vs. Progressive stereotypes. Certainly easier to appeal to those than address the issue of only having shoddy evidence.

In conclusion, before the BCA is further dragged through the mud by a concerted smear campaign, consider this: chiropractic has made huge strides to integrate itself into mainstream UK health care. It has enjoyed phenomenal popularity that is based on consistently delivering high quality care. As a modern healthcare profession it welcomes examination of its methods, yet libellous statements are not the modus operandi that critics should employ.

Again Richard seems to genuinely not grasp that the one dragging the BCA’s reputation through the mud is the BCA by pursuing this case. The BCA has not defended its reputation with this legal action instead this legal action has lead to the BCA receiving what amounts to probably the most negative press coverage it has received in decades. Whatever reputation the BCA once had in the eyes of most of who read about this case it’s reputation is being done untold amounts of harm. The best it can hope for at this stage is a legal victory that will neither vindicate its claims nor silence its critics.

As for chiropractic making strides to integrate into mainstream UK health care. Why should anyone beside chiropractors care about that? Homeopathic and a whole raft of other alternative medicine modalities can claim to have made similar strides in recent years but that is not cause for celebration for anyone except the alternative medicine practitioners. The evidence for alternative medicine is still just as non-compelling as it has always been all that has changed is the political environment which is now more  receptive to CAM initiatives.

And in regards the ‘phenomenal popularity’ of chiropractic treatments well homeopathy is also very popular in the UK. Being popular does not mean that the treatments offered are actually effective it just means people believe they are. For CAM advocates that distinction rarely matters but for those who care about medicine actually being evidence based it matters a lot.

Finally, describing chiropractic as “a modern healthcare profession” is a bit like describing astrology as “a modern life advice system”. Just because something exists in the modern world does not make it modern and chiropractic is definitely not based on a ‘modern’ understanding of the body. This does not mean that there are not those in the chiropractic profession who do base their practice on a modern understanding of the body and try and keep their treatments evidence based. Undoubtedly there are, but Richard is definitely misrepresenting the profession as a whole by presenting it as a profession that “welcomes examination of its methods”. Sueing people is not welcoming examination it is in fact punishing it.

Richard Brown is an eloquent writer and well versed in his alternative medicine rhetoric but unfortunately no amount of eloquence or rhetoric can save his arguments from displaying the fundamental weakness that there is no real evidence for what the BCA claims.