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Old 24th November 2007, 04:20 AM   #1
Blue Wode
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Angry UK chiropractic regulators write to the Press Complaints Commission

Here is an interesting development concerning the practice of chiropractic in the UK.

The chiropractic regulatory body, the General Chiropractic Council (GCC), has just lodged a formal complaint with the Press Complaints Commission (PCC) against three UK newspapers for “inaccurate, misleading and distorted reporting of the purpose and outcome of a research study”.
http://www.gcc-uk.org/files/page_fil...0(Website).pdf

The research study in question found that there was no significant difference in the time to recovery, pain, function, global perceived effects or adverse events between people receiving active diclofenac and/or spinal manipulation compared to the respective placebo. The study’s Discussion section (p.1643) included the following comments:

Quote:
The spinal manipulative therapy given in this trial included a range of low-velocity mobilisation and high-velocity manipulation techniques done by physiotherapists with postgraduate training in manipulative therapy. A systematic review of spinal manipulation concluded that there is no evidence that high-velocity spinal mobilisation is more effective than low-velocity spinal manipulation, or that the profession of the manipulator affects the effectiveness of treatment.

Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial Hancock MJ et al; Lancet:370:1638-43

http://www.acatoday.org/pdf/Lancet_A...ain_Nov.07.pdf

According to the GCC the offending newspapers are:
  • Chiropractors ‘are a waste of money’, Daily Telegraph, Rebecca Smith
  • Chiropractors ‘are a waste of time’, Daily Mail, Jenny Hope
  • ‘Chiropractors may be no use in treating back pain, study says’, The Guardian, Alok Jha

Note that the The Guardian headline read "Chiropractors may be no use in treating back pain, study says".

[My bold]

Now, remembering that in the UK legislation requires that chiropractors’ provision of care must be evidence-based and that spinal manipulation is about the only treatment that chiropractors administer that has some (very slim) evidence attached to it, those headlines may carry more than a kernel of truth in them.

For those not familiar with the evidence base for spinal manipulation (which is not strictly ‘chiropractic’) here are the current data:

From 2005
Quote:
Virtually all experts agree that the best available evidence in any area of health care is that provided by Cochrane reviews. The Cochrane Collaboration is a worldwide network of independent scientists dedicated to systematically summarising the totality of the evidence related to specific medical subjects in a rigorous and transparently impartial fashion. Four Cochrane reviews of spinal manipulation are available today.Back pain is by far the condition most frequently treated by chiropractors. The Cochrane review of spinal manipulation for back pain summarised 39 clinical trials.1 The authors’ conclusions were very clear: ‘There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.’

More…

The Value of Chiropractic
http://www.medicinescomplete.com/jou...1002a02t01.htm
From 2006
Quote:
A systematic review of systematic reviews of spinal manipulation

CONCLUSIONS: Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.

http://www.jrsm.org/cgi/content/abstract/99/4/192
From 2007
Quote:
Adverse effects of spinal manipulation: a systematic review

CONCLUSIONS: Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissection followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.

http://www.jrsm.org/cgi/content/abstract/100/7/330

Still on the subject of evidence, it is interesting to note that the GCC’s 9th November 2007 press statement regarding the study published in the Lancet said the following:

Quote:
Chiropractors provide an evidence-based approach based on European-wide guidelines compiled by multidisciplinary teams of experts who reviewed all relevant research.

The main treatments of chiropractic have been shown consistently in reviews to be more effective than the treatments to which they have been compared. Chiropractic intervention is safe, effective and cost-effective in reducing referral to secondary care.

http://www.gcc-uk.org/files/page_fil...ment9Nov07.pdf

Well, just where is the scientific evidence to support the GCC’s claims that “The main treatments of chiropractic have been shown consistently in reviews to be more effective than the treatment to which they have been compared”?

And where are the safety data for ‘chiropractic’ (including those for children), and the data for chiropractic’s effectiveness and for its cost-effectiveness?

And what about those national guidelines? Here's some insight into them:

Quote:
Chiropractors argue that their approach must be safe and effective, not least because the official guidelines on the treatment of back pain recommend using chiropractic. However, this is true only for some, but by no means all, countries. Secondly, guidelines are well known to be influenced by the people who serve on the panel that develops them. Cochrane reviews, on the other hand, are generally considered to be objective and rigorous. Writing about the importance of systematic reviews for health care in the Lancet, Sir Ian Chalmers stated, ‘I challenge decision makers within those spheres who continue to frustrate efforts to promote this form of research to come out from behind their closed doors and defend their attitudes and policies in public. There is now plenty of evidence to show how patients are suffering unnecessarily as a result of their persuasive influence.’ 10

The Value of Chiropractic
http://www.medicinescomplete.com/jou...1002a02t01.htm

Returning once more to its formal complaint to the PCC, the GCC says that it is concerned that the newspapers’ reporting is…

Quote:
irresponsible and does not serve the public interest. It misleads readers, may prevent members of the public from seeking the help of appropriately qualified, experienced and regulated health professionals, and ultimately undermines the public’s trust in the accuracy and utility of scientific research.

It is likely that such reporting has also undermined the reputation of the chiropractic profession and may have a direct impact on chiropractors’ practices; all chiropractors, apart from a handful, are in private practice. It may also prejudice any chance of increasing public access to chiropractic on a basis of need through NHS funding.

…and it is seeking corrections and clarifications printed in prominent positions in each paper.

Well, presumably any such correction will be accompanied by the scientific evidence for ‘chiropractic’ (whatever chiropractic actually is), and it will also justify why several hundred McTimoney chiropractors (as well as quite a number of others) are allowed to promote the pseudoscientific concept of “innate intelligence”.

For example:
Quote:
“By correctly training hands as an instrument of innate intelligence, healing can be encouraged to take place by the detection and correction of bony subluxations (slight displacements)”.

http://www.mctimoney-chiropractic.or...objectives.htm

Finally, it’s interesting to note the following in the GCC’s complaint to the PCC:

Quote:
Treatment with NSAIDs or spinal manipulative therapy is recommended as second-line treatment for acute back pain in patients not responding to first-line management.

What it doesn’t say is that that recommendation isn’t true of the Royal College of General Practitioners (RCGP) in the UK. Its guidelines for the management of acute low back pain - which had previously recommended spinal manipulation – were withdrawn two years ago. See page 2 of the GCC’s Spring 2005 newsletter (#15) here:
http://www.gcc-uk.org/files/link_file/GCC_news_15.pdf

Does anyone else think that the GCC, as part of its regulatory duty to 'promote the profession', is equally guilty of inaccurate, misleading and distorted reporting?

Last edited by Blue Wode; 24th November 2007 at 04:28 AM. Reason: Clarification
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Old 24th November 2007, 05:17 AM   #2
Zep
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Let's see what the upshot of their complaint is. They may get slapped down hard!
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Old 24th November 2007, 03:40 PM   #3
fuelair
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Originally Posted by Zep View Post
Let's see what the upshot of their complaint is. They may get slapped down hard!
Let's hope they stop being licensed as if they were real medical functionaries.:
Here too!!!!
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Old 25th November 2007, 04:18 AM   #4
Blue Wode
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Well, the Daily Telegraph has now published a very brief apology. However, what I’d like to know is how the General Chiropractic Council can say this…

Quote:
The main treatments of chiropractic have been shown consistently in reviews to be more effective than the treatment to which they have been compared. Chiropractic intervention is safe, effective and cost-effective in reducing referral to secondary care.

http://www.gcc-uk.org/files/page_fil...ment9Nov07.pdf

…when this seems to be the reality of the situation:

Quote:
Spinal manipulation: are the benefits worth the risks?

Spinal manipulation is a form of treatment that is used occasionally by some doctors, physiotherapists and osteopaths – but, for chiropractors, it is the hallmark intervention.

-snip-

To answer the question of whether spinal manipulation is effective, we need to look at the results of controlled clinical trials. Currently, there are well over 100 such studies. Unsurprisingly, their results are not uniform. In order to create the most reliable overall picture possible, we must thus resist the temptation of selecting those trials which, for whatever reason, we might like. The best way forward is to critically evaluate the totality of the reliable evidence – in other words, it is best to rely on well-conducted systematic reviews of high-quality clinical trials.

A recent overview of the most up to date and authoritative systematic reviews found such articles relating to a range of indications: back pain, neck pain, headache, dysmenorrhoea, asthma, infantile colic and cervicogenic dizziness [2]. This seems to confirm that spinal manipulation is purely meant as a treatment for musculoskeletal problems. The Cochrane review of the back pain trials suggested that spinal manipulation is as good (or bad) as conventional treatments in easing pain or improving function. For all other conditions, the systematic reviews were even less encouraging: there was no definite evidence that spinal manipulation was effective on any of them [2].

Treatment decisions cannot not be based on effectiveness data alone. Another important factor obviously is safety. It is in this respect that spinal manipulation disappoints most. Several large-scale surveys have shown that approximately half of all patients suffer mild-to-moderate symptoms, such as pain, after receiving spinal manipulation [3]. As these problems are usually gone within 24 h, one could perhaps agree with the view of most chiropractors that these adverse effects are negligible and form part of the process of recovery. One is, however, far less inclined to take serious complications lightly. Approximately 700 cases of serious adverse effects have been associated with spinal manipulation [4]. They frequently relate to upper spinal manipulation, which can entail manipulative movements beyond the physiological range of motion. This can conceivably lead to injuries, most frequently to dissections of the vertebral arteries. Such cases often present as strokes, which can sometimes be fatal [4].

Many chiropractors deny that a causal relationship exists between spinal manipulation and such complications [1]. Others argue that these incidents are extreme rarities and provide figures of one in three million patients [1]. Our own research shows that under-reporting of serious complications can be as high as 100% [5]. Therefore, estimates are simply not possible and the 700 documented cases [4] are likely to be the tip of a much bigger iceberg.

Weighing the risks of spinal manipulation against its benefits is therefore an exercise that involves a considerable amount of uncertainty. Whenever uncertainty exists, it seems wise to err on the side of caution. Applying the cautionary principle to spinal manipulation generates discouraging evidence. For most indications, there is no evidence of benefit [2]; therefore, any risk–benefit assessment cannot result in a positive verdict. For back pain, the situation is slightly more complex. Here, we do have evidence that spinal manipulation is as effective (or as ineffective) as conventional options, including physiotherapeutic exercise [2]. But, on the risk side of the balance, we have mild-to-moderate adverse effects in approximately 50% of all patients [3] and serious complications of unknown frequency [4]. Compare this with exercise, which has no known serious risks, and you will probably find it difficult to recommend spinal manipulation even for back pain.

In conclusion, spinal manipulation is based on questionable pathological concepts and therefore lacks biological plausibility [1]. Its risks may be considerable [4] and its benefits have not been convincingly demonstrated in rigorous trials [2]. What follows is sobering: the benefits of spinal manipulation do not seem worth the potential risks.

E. Ernst, Expert Review of Neurotherapeutics
November 2007, Vol. 7, No. 11, Pages 1451-1452
http://www.future-drugs.com/doi/abs/...7175.7.11.1451
[My bold]

Interestingly, in addition to “promoting the profession” the General Chiropractic Council has a duty to “protect patients” and “set standards”.

Conflict of interests?


ETA: Re cost effectiveness of spinal manipulation, here are the most up-to-date (2006) data:

Quote:
Prospective, controlled, cost-effectiveness studies of complementary therapies have been carried out in the UK only for spinal manipulation (four studies) and acupuncture (two studies). The limited data available indicate that the use of these therapies usually represents an additional cost to conventional treatment.

Cost-Effectiveness of Complementary Therapies in the United Kingdom—A Systematic Review
http://www.pubmedcentral.nih.gov/art...medid=17173105

Last edited by Blue Wode; 25th November 2007 at 04:24 AM.
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Old 19th November 2010, 03:42 PM   #5
Blue Wode
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It's been three years, but finally UK chiropractors and their regulator, the General Chiropractic Council, have been caught out with the above:

Where the evidence leads
http://www.zenosblog.com/2010/11/whe...vidence-leads/

Has the self-destruct button been pressed?
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Old 20th November 2010, 01:52 AM   #6
Badly Shaved Monkey
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Ah, the joys of the web. All it takes is some diligent soul to link the dots and the internal inconsistencies and self-contradictions become evident.

Without wishing to derail, "Dana Ullman" has caught himself in a similar bind, albeit one that matters less in the great scheme of things.

Unfortunately, what we lack is a great big buzzer that goes off when one of these gets spotted and the defeated party is forced to remove themself from the field of play forever.
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Old 23rd November 2010, 04:15 PM   #7
zeno2712
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Originally Posted by Badly Shaved Monkey View Post
Unfortunately, what we lack is a great big buzzer that goes off when one of these gets spotted and the defeated party is forced to remove themself from the field of play forever.
That would be a fantastic invention!
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