Wednesday, July 29, 2009

Beware The Spinal Trap - Lawyer-friendly reprint

Just in case you haven't been to your chiropractor in the last little while due to the recession, there has been a maelstrom.

Science writer Simon Singh wrote an article for the Guardian which the British Chiropractic Association claimed libelled them and so went the way of the courts. Justice Eady decided there were words used which conveyed a meaning which Singh had not intended, but that the case should go to trial nonetheless. Singh is appealing the decision.

In the meantime, the searchlight of skepticism was directed towards chiropractic. Hundreds of complaints were sent to the General Chiropractic Council meaning the GCC were unable to cope with the volume of complaints and causing some chiropractors to rapidly remove or rehash their websites, with some of them throwing in the towel and admitting that Chiropractic has never cured anyone of anything.

Sense about Science has been working with Singh to campaign to keep libel laws out of science.

As part of that, they have arranged for Singh's original article to be scanned by lawyers, have the few words removed that were called into question, so that the article can be reprinted without fear of libel. The important point of this article is that, the whole feel, meaning and impetus is unchanged by the removal of a few contentious words. The thrust of the article is the statement of fact that there is little/no evidence for most (all?) of the claims of chiropractic.

I am pleased to reprint the lawyer-friendly article below - it should also be noted that the BCA have no issue (and therefore tacitly agree with?) everything in the article below.

Beware the spinal trap

Some practitioners claim it is a cure-all, but the research suggests chiropractic therapy has mixed results – and can even be lethal, says Simon Singh.

You might be surprised to know that the founder of chiropractic therapy, Daniel David Palmer, wrote that “99% of all diseases are caused by displaced vertebrae”. In the 1860s, Palmer began to develop his theory that the spine was involved in almost every illness because the spinal cord connects the brain to the rest of the body. Therefore any misalignment could cause a problem in distant parts of the body.
In fact, Palmer’s first chiropractic intervention supposedly cured a man who had been profoundly deaf for 17 years. His second treatment was equally strange, because he claimed that he treated a patient with heart trouble by correcting a displaced vertebra.
You might think that modern chiropractors restrict themselves to treating back problems, but in fact some still possess quite wacky ideas. The fundamentalists argue that they can cure anything, including helping treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying – even though there is not a jot of evidence.
I can confidently label these assertions as utter nonsense because I have co-authored a book about alternative medicine with the world’s first professor of complementary medicine, Edzard Ernst. He learned chiropractic techniques himself and used them as a doctor. This is when he began to see the need for some critical evaluation. Among other projects, he examined the evidence from 70 trials exploring the benefits of chiropractic therapy in conditions unrelated to the back. He found no evidence to suggest that chiropractors could treat any such conditions.
But what about chiropractic in the context of treating back problems? Manipulating the spine can cure some problems, but results are mixed. To be fair, conventional approaches, such as physiotherapy, also struggle to treat back problems with any consistency. Nevertheless, conventional therapy is still preferable because of the serious dangers associated with chiropractic.
In 2001, a systematic review of five studies revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches. These are relatively minor effects, but the frequency is very high, and this has to be weighed against the limited benefit offered by chiropractors.
More worryingly, the hallmark technique of the chiropractor, known as high-velocity, low-amplitude thrust, carries much more significant risks. This involves pushing joints beyond their natural range of motion by applying a short, sharp force. Although this is a safe procedure for most patients, others can suffer dislocations and fractures.
Worse still, manipulation of the neck can damage the vertebral arteries, which supply blood to the brain. So-called vertebral dissection can ultimately cut off the blood supply, which in turn can lead to a stroke and even death. Because there is usually a delay between the vertebral dissection and the blockage of blood to the brain, the link between chiropractic and strokes went unnoticed for many years. Recently, however, it has been possible to identify cases where spinal manipulation has certainly been the cause of vertebral dissection.
Laurie Mathiason was a 20-year-old Canadian waitress who visited a chiropractor 21 times between 1997 and 1998 to relieve her low-back pain. On her penultimate visit she complained of stiffness in her neck. That evening she began dropping plates at the restaurant, so she returned to the chiropractor. As the chiropractor manipulated her neck, Mathiason began to cry, her eyes started to roll, she foamed at the mouth and her body began to convulse. She was rushed to hospital, slipped into a coma and died three days later. At the inquest, the coroner declared: “Laurie died of a ruptured vertebral artery, which occurred in association with a chiropractic manipulation of the neck.”
This case is not unique. In Canada alone there have been several other women who have died after receiving chiropractic therapy, and Edzard Ernst has identified about 700 cases of serious complications among the medical literature. This should be a major concern for health officials, particularly as under-reporting will mean that the actual number of cases is much higher.
If spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.

Simon Singh is a science writer in London and the co-author, with Edzard Ernst, of Trick or Treatment? Alternative Medicine on Trial. This is an edited version of an article published in The Guardian for which Singh is being personally sued for libel by the British Chiropractic Association.


Sunday, July 19, 2009

Acupuncture needles no good as toothpicks...

...yet funny enough toothpicks are just as good as acupuncture needles for providing relief of lower back pain.

The reference is
DC Cherkin et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Archives of Internal Medicine 2009 169: 858-866
but evidence-based healthcare knowledge collater, Bandolier has written a plain, easy-to-digest synopsis of the paper here.

The study looked at four therapies; individualised acupuncture, standardised acupuncture, simulated acupuncture with toothpicks and lastly, usual care. From Bandolier:

This large trial involved 638 adults, with follow up of 90% or above up to 52 weeks. Participants had an average age of about 47 years, with about 60% being women. About 70% had back pain for at least a year. The average initial RMDQ score was about 10.5 on a 0-24 scale, and average initial bothersomeness score 5 on a 0-10 scale.

The main results were these:

* There was no difference between individualised acupuncture, standardised acupuncture, or sham acupuncture.
* RMDQ scores fell from 11 to 6 for acupuncture of any sort by 52 weeks, compared with 7.9 for usual care. Any form of acupuncture was better than usual care.
* Bothersomeness scores fell from 5 to 3-5 to 4 for all four groups, with no difference between them.
* Use of medications (about 65% at baseline) fell to 47% with acupuncture, but remained at 59% with usual care.
* There was no difference in SF-36 mental and physical component scores.
* Cutting down on usual activities for more than seven days in the last month at 52 weeks was more common with usual care (18%) than with acupuncture.
* More participants with usual care missed work or school for more than a day (16%) than with acupuncture (5%-10%).
* There was no difference in total costs of back related health services between groups ($160-$221), though costs of acupuncture were not included.
* Adverse events occurred in 12/315 with real acupuncture, compared with 0/162 for simulated acupuncture, with one serious adverse event for real acupuncture.
* One patient in the usual care group went on to have back surgery.

There are a few interesting things that came out of the study.

The difference between standard care and intervention is significant, and confirms previous discussions suggesting the more theatrical the intervention the larger the placebo effect.

Secondy, the cost comparison is interesting - no real cost difference, and indeed acupuncture costs weren't included. So even the 'cost effective' argument is unfounded.

Thirdly, adverse effects - one serious adverse effect and 12 lesser, compared with zero for the toothpicks. This means about 4% of the patients had an adverse effect from a treatment which had absolutely no demonstrable benefit compared to toothpickery.

So let's see: there's no patient benefit, no cost benefit and increased risk of adverse effects. So why are NICE approving it for lower backpain?

Perhaps I'll drop them a line.

(How long do you reckon it'll be before a quackupuncturist declares that this proves acupuncture works, and the toothpicks were "accidently" letting the Qi energy move as it should?)


Monday, July 13, 2009

General Chiropractic Council unable to cope with complaints

According to a letter shown to this blog, the General Chiropractic Council has written to complainants and chiropractors saying that it can not cope with the number of complaints it has received (590 last month compared with 40 per year).

The GCC have stated that
it will be necessary to increase our regulatory staff capacity before we issue formal notification of any complaints relating to chiropractic websites.

The lack of staff will delay the commencement of the formal process until September 2009. The increase in complaints was due to the British Chiropractic Association's attempt to silence criticism about claims for chiropractic being an evidence-free zone.

If the BCA had been a bit less foolish, it could have avoided this whole debacle, but it appears that it was spoiling for a fight, and is looking pretty groggy.


Wednesday, July 8, 2009

Chiropractors admit "Chiropractic has never cured anyone of anything"

PLEASE NOTE Since writing this blog, Glasgow Chiro have revamped their webpage, hence some of the links may no longer work. A more recent article on Glasgow CHiro's website can be found here.

Recently, I blogged about Glasgow Chiropractic changing their website to remove references to colic.

Previous posts on this site have demonstrated that evidence-free claims about the ability of chiropractors to cure/treat period pains, carpal tunnel syndrome and asthma are routinely appearing on chiropractor's websites - in the blogposts above, I linked to Glasgow Chiropractic as an example.

A specific complaint about the contents of their website had been sent to the GCC and so, using, I was able to see how Glasgow Chiropractic would react.

As a pleasant surprise, the chiropractors seem they have come over all hand-wringy and repentant and have updated their website accordingly.

The change detection page for menstrual pain is here and the one for shoulder pain and carpal tunnel syndrome is here. You can see the changes made by clicking on " View changes: 2009-07-08 13:57" about half way down on the left hand side.

The new page on shoulder pain is here and contains the bold title
Chiropractic has never cured anyone of anything.

Quite an admission, although one that is completely backed up by research data.

The new addition to the website goes on to say:
If we go looking for the named condition that Chiropractic can be applied to and produce change in we will find ourselves in a merry-go-round of symptoms, loosing [sic] sight of the whole because of an obsession with the parts.

So the question of What can Chiropractic Cure should be changed to "How" can Chiropractic Assist? The answer is simple. A well functioning mind and body has a greater opportunity to heal, repair and function than a poorly functioning one. A well functioning mind and body depends to a significant degree on a well functioning spine and nerve system. This is Chiropractic's contribution.

People find that chiropractic's ability to produce better spine and nerve system function changes their life expression. There are thousands of symptoms and conditions that chiropractic has been associated with helping, however don't ask "Can Chiropractic Cure this or that condition" - instead ask "If my mind and body was functioning better through Chiropractic would I be better placed to handle this condition?"
Have you got that? Don't ask "can chiropractic cure". Just don't. Ask a different question if you must, but don't ask if it can cure.

The page on menstrual pain contains an almost identical admission along with postmodern flakery but has some interesting text manipulations further down (new text in bold, previous text in brackets/italics)

Chiropractic management of dysmenorrhoea

When helping (treating) women who suffer from dysmenorrhea, the majority of chiropractors address only problems located in the areas directly involved in causing the symptoms. In a study conducted to establish which styles of Chiropractic care (treatments) are most frequently used by chiropractors for dysmenorrhea, manipulation was used in 100% of the cases.
Read that last sentence again in its old and new forms - the meaning has been changed to the point of silliness. Although perhaps they are now referring to a different study? Who knows.
A chiropractor’s role is to normalise the functions of the body by correcting spinal problems. The rationale behind the chiropractic management (treatment) of women suffering from dysmenorrhea is to deal with (treat) its spinal and skeletal aspect.

Chiropractic provides the mechanisms through which dysmenorrheic women can be relieved of their pain in a drug-free environment and even go on to live a life free of period pain.

How (What) can Chiropractic assist with (a Chiropractor do for) menstrual pain?

Your chiropractor will perform a complete consult and examination and may take radiographs (x rays) if clinically required.). After review of the examination findings your chiropractor will recommend an appropriate and individual care program. Chiropractic care (Treatment) consists of specific manual adjustments, to the individual joints of the body and spine, which restore damaged neurologic function. As Grey’s Anatomy text states every single organ in the body is controlled by the nervous system. This includes the uterus and reproductive systems. Through the specific adjustment your chiropractor provides neurological input (imput) that allows your nervous system, and so your organs, to adapt to environmental stresses.

So by changing the word 'treat' to 'help' or similar, that makes it all ok. It's good to see that the X-rays are now only done 'if clinically required'.

Will that ever be the case if chiropractic has never cured anyone of anything?


Wednesday, July 1, 2009

MHRA publish public assessment of homeopathic arnica, admit it does nothing, but license it anyway

Just off so no time to blog this properly, but back in May I blogged about the Medicines and Healthcare Products Regulatory Agency giving their blessing to Nelson's selling homeopathic arnica with therapeutic indications.

The full report is now published and can be found here.

A few choice quotes for your discussion:

The homeopathic medicinal product consists of white to off-white spherical pillules
for oral administration, containing 30c (GHP) Arnica montana. It is used for the
symptomatic relief of sprains, muscular aches and bruising and swelling after
contusions. Two pillules should be taken every 2 hours for the first six doses, then
four times daily until symptoms improve for up to a maximum of 7 days.

The excipients used to manufacture the homeopathic medicinal product are lactose,
sucrose and purified water.
Oh, no arnica then?
This bit is utterly laughable:
Published scientific literature review
The applicant has provided a bibliographic reference documenting a summary of
clinical trials using arnica in homeopathic dilutions. The summary refers to studies
where Arnica had been administered in a number of clinical conditions.
The applicant has also provided further details of eleven published clinical studies
investigating the clinical effects of arnica. The studies were performed under
randomised, double blind conditions and were carried out to investigate the post
operative clinical actions of arnica, such as pain relief and bruising.
The results of the clinical trials and studies provided were not conclusive in
establishing the clinical effects of arnica but indicated that there may be a trend
towards demonstrating some beneficial effects of arnica in some situations.

I'll be contacting the MHRA as they seem to have omitted an important safety concern - how do I know that what is in the pack is what is on the label? Both you, I, MHRA and Nelson's know it is impossible to tell.