A few days ago ‘Charles’ a chiropractor left quite an extensive comment on an post from a few months back about the Simon Singh case. Since his arguments are raised frequently I felt  it would be useful to offer a response and I also decided that if I was going to compose a long response I might as well put it in a new post where it may be read (at least by someone).

So here is my response to Charles the chiropractor…

I am a practicing chiropractor with some research experience, albeit minimal. I find the tennor the discussions intriguing. This is because I fail to see why there is such an emotional charge about the whole issue, particularly to those who appear to have no involvement in the issues at hand.

I think the emotional involvement comes from a very tangible sense that a science writer being sued for telling the truth about the lack of evidence for chiropractic claims is a sincere injustice. This initial reaction then combined with further frustration and bemusement as the BCA dispatched increasingly silly and vindictive press releases. If the BCA had not sued Simon Singh and instead decided to write an article in response, like Simon and the Guardian offered, the case would never have attracted the attention it has.

So in essence it is the BCA’s attempt to use Britain’s deeply flawed libel laws as a weapon that has focused so much attention on the situation.  Generally speaking when well financed organisations try to silence lone critics with legal threats it never goes down very well with the public. And in Simon’s case it has gone down especially poorly because the critic in question is a well regarded science journalist who was telling the truth about the state of the scientific evidence.

I know mine is that I have worked with patients for 28 years and have never advertised or promoted myself in any way that I could not substantiate through the evidence, most usually the best evidence was patient outcome to care. Over the years it became interesting to me when patient coming in for low back or neck pain would remark that some other non-musculoskeletal issue resolved, but I just chalked that up to coincidence.

Herein lies an excellent illustration of how chiropractors routinely misunderstand what counts as compelling evidence in evidence based medicine. The fact that people feel better after receiving treatments is NOT an indication that the treatment is effective. Intuitively, it may seem that way but there is a tonne of research demonstrating that people tend to report improvements when they receive ANY treatment- including fake placebo treatments! This is why treatments which have been proven to be useless or harmful, such as bleeding, were praised as effective by healers for centuries. History demonstrates that when all we have to go on is fallible human perception and anecdote, medicine doesn’t progress very quickly and many useless and harmful treatments remain popular.

When I attended chiropractic college I had never been to a chiropractor and was extremely skeptical. The fun for me as a pracitioner is being skeptical at all times but also trusting my feelings which are difficult to quantize. This is similar to quantitative versus qualitative chemical analysis. The qualitative part leads to the “art” of chiropractic whereas the quantitative portion to the scientific aspect.

1. It is highly unlikely that you had no interest in chiropractic and were very skeptical towards chiropractic if you chose to attend a chiropractic college!
2. No-one is suggesting that you cannot make use of personal experience and judgement in medicine. What they are suggesting is that personal experience does not trump clinical trials and that before you start promoting a treatment for an illness (especially for childhood ailments) you should at least have some evidence that it works beyond the placebo effect.

For me the main issue that seens to be glossed over is that most healthcare interventions offered by clinicians have a limited evidence base of high level research. That is why the term evidence based practice is coming into vogue. With evidence based practice we see that included in a clinical decision is the doctor’s experience which incorporates the multifactorial unique nature of each and every patient.

Stealing from my earlier response to another chiropractor who made essentially the same point:

Arguments concerning the lack of evidence for certain mainstream treatments are over exaggerated. Proving to be more effective than a placebo is a basic requirement for a mainstream medicine and while it is true that treatments have, occasionally, been later found to be no better than a placebo, when this has occurred it is generally big medical news and the treatments are abandoned.

I wonder if this has ever happened in the history of chiropractic? Are there any treatments previously considered effective that have later been studied and found to lack evidence and be removed? There are none I know of and this is the general pattern one sees in practically all forms of alternative medicine. This indicates a severe problem namely chiropractic, as with most alternative medicines, seems to be more about tradition than about evidence.

However, even if we accept your point and agree that mainstream medicine has treatments which are not supported by good evidence. This does not help validate chiropractic treatments. Indeed, it just serves to further illustrate that we need to more rigorously evaluate the evidence basis for treatments so we are not just promoting placebos.

Also, the notion that chiropractors take a more holistic approach to treating patients is somewhat contradicted by the fact that for almost every ailment it will be a spinal manipulation that will be the prescribed treatment. On top of this it is simply false to suggest that mainstream doctors do not treat the patients as individuals. If they didn’t why would they bother with things like collecting patient histories?

There is a valid point to be made about the amount of attention doctors afford individual patients but simply providing a greater amount of attention does not prove that chiropractic treatments work. A person who gets healing crystal treatments will likely get more time and attention than they would on a GP visit too so would you argue that crystal therapy should be respected as a valid medical treatment too?

With the limited nature of most healthcare evidence a higher level of stress should be placed upon risk benefit ratios. I do know that determining benefit can be a difficult path to walk since no chiropractic adjustment sham has been properly validated and it is hard to blind a patient and doctor from the chiropractic treatment process.

Really? I can think of a rather straightforward way.

You take a group of patients who are unfamiliar with chiropractic treatments, you provide them with a standard chiropractic consultation and then split them into two groups. The first group then receives a treatment from a different chiropractor (presumably working on instructions from the first) and the second group receives a treatment from some sort of massage therapist (and if you want to be flash you could throw in a placebo pill group/no treatment group). During the treatments the individuals are not allowed to speak the patients only provide the treatment to avoid influencing the patient or accidentally revealing their identity. Then you look at the results and you see if there is a difference between a simple massage and a chiropractic treatment. If there is no difference then uh oh… and if there is then great news for chiropractors!

That is an example off the top of my head but yet it is better designed than most of the trials the BCA referenced during the Singh case. It is really not that difficult to think of ways to test if treatments work better than a placebo.

However risk can be readily identified and comparisons can be made of patients who have head, neck and low back pain and compare the alternatives, which is not usually doing nothing. What are the associated risks with medication or other more invasive procedures?

How about the risks associated with massage therapy or regular exercise classes which tend to cost a lot less and provide the same benefit? Doctors aren’t always so quick as alternative medicine practitioners believe to recommend surgery for every minor ache and pain.

What about non-musculoskeletal complaints and chiropractic care? If the risk of a procedure is low, the patient has attempted other interventions and are not willing to either accept the associated risks, side effects, or choosing to do nothing, then some alternative with low risk might be worth investigating. The question involves then how much evidence and what level of evidence is necessary for a patient to attempt a low risk intervention such as chiropractic for a non-musculoskeletal condition?

Here you are assuming that patients would only seek out chiropractic treatments after exhausting all other avenues but this is not how chiropractic is advertised. Chiropractors don’t generally say ‘hey there is no real evidence this will help but since you’ve done everything else why not give our treatment a go?’ They say chiropractic can be effective in treating common childhood ailments such as colic, ear infections, bed wetting and so on. Is manipulating a child’s spine when they have an ear infection really a low risk treatment?

I do not believe that every child with colic, bed wetting, sleep disturbances or whatever need chiropractic care or would systematically benefit. But I do believe that clinically significant percentage would. The difficulty is getting the research community to embrace this type of study and like Jon C noted the pharmaceutical community and those outside of chiropractic are not interested. Developing a clinical prediction rule for patients with non-musculoskeletal complaint that could be treated by chiropractors would be an intriguing study.

Unfortunately you have no evidence for your intuitions because no good studies exist. If it is a significant group that would benefit then it should show up in a well designed study. However, if you are talking about something like 1 in 50 people might think it helped them with something then that is not likely to be statistically significant and in fact it is much more likely that such a result would be down to a simple coincidence. Bodies heal and people often take medicine at the same time as they are receiving chiropractic treatments so the fact that you there are going to be some patients reporting random benefits is not surprising nor should it be taken as evidence that chiropractic works for non-musculoskeletal problems.

As regards the failure of the ‘research community’ to investigate chiropractic properly, hang on, shouldn’t that be the job of the chiropractors? They are the ones claiming the effect so they should be the ones demonstrating it by publishing well designed trials and thus attracting interest and funding. There are national bodies of chiropractors which have research grants and there are many alternative medicine research programs so what are the chiropractors waiting for?

I have found, not exclusively, that some patients who have a physical trauma associated with a non-musculoskeletal complaint sometimes will have their non-musculoskeletal complaint resolve as they receive treatment for their physical trauma. That might be one factor that could be utilized in differentiating patients. But the issue is that the ratio of patients with non-musculoskeletal complaint helped by chiropractic care would be low and that would mean a large sample for a study would be needed for it to generate worthwhile information.

This sounds like exactly the kind of pattern you would record if there was no real correlation. Imagine if dentists asked their patients about their other ailments and claimed to be able to help them by treating their teeth. You would likely find a very small number of individuals who reported that some of their other ailments were cured after they received the dental treatment. That does not mean dental treatments are able to help with ear infections which is the kind of conclusion you seem to be drawing from the same kind of evidence.

I like the idea of a large well designed study but what about the already existing large negative studies? Do they give any pause for thought?

Does anyone know how much funds it would take to coordinate such a study? Who is willing to take it on? Wouldn’t it be something a government would want to investigate for its people? A relatively low cost, low risk procedure for a subset of patients suffering from various non-musculoskeletal complaints would save money and improve general public health. I know I would be happy to volunteer my time to be part of this study. I like most of my chiropractic colleagues just want to help our fellow man (and woman) and would love to have more information, research, and answers to help guide us.

It is somewhat telling that you have been a chiropractor for 28 years and yet have seemingly no familiarity with how you would even go about getting research organised. It is a positive sign that you are interested in conducting or taking part in clinical trials but doesn’t it seem a bit backwards that you and the BCA are already promoting treatments for ailments which you don’t have any evidence that they work for? Do you mention that to your patients?

I suggest a good first step to getting involved with research would be to read the literature and contact some of the respected researchers, like any of the folks from Edzard Ernst’s group for instance. I’m sure they could point you in the right direction.

I know that most chiropractors are not bad people and are often motivated by a desire to help people. The problem is that just having the intention to help does not mean the treatment you provide therefore really works. That is why it is important to get good evidence that a treatment really helps BEFORE you promote it for an ailment. Otherwise you can not be sure that what you are offering is not just a fancy placebo. Unless of course you are happy treating people with a fancy placebo but I don’t see many chiropractors willing to take that stance.

Well that’s all I look forward to your response if you come across this.