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By Josh Witten | June 16th 2009 01:34 PM | 22 comments | Print | E-mail | Track Comments
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About Josh Witten

100% of this the rugbyologist's revenue is donated to Doctors Without Borders (Medecins Sans Frontieres). A click on one of my articles is a click that helps bring high quality medical care to the... Full Bio


Following the initial finding by the incomparable Judge Eady in Simon Singh's libel case, one would think that British chiropractors would be feeling pretty good about life.  Yet, like the creepy crawlies of lore, some British chiropractors are finding the bright glare of scrutiny a bit much. A letter from the McTimoney Chiropractic Association was apparently sent its members on 8 June 2009.  The letter was made public by an apparently disgruntled chiropractor on 9 June 2009.

Here is the letter:

Date: 8 June 2009 09:12:18 BDT

Subject: FURTHER URGENT ACTION REQUIRED!

Dear Member

If
you are reading this, we assume you have also read the urgent email we
sent you last Friday. If you did not read it, READ IT VERY CAREFULLY
NOW and - this is most important – ACT ON IT. This is not
scaremongering. We judge this to be a real threat to you and your
practice.

Because of what we consider to be a witch hunt against chiropractors, we are now issuing the following advice:

The
target of the campaigners is now any claims for treatment that cannot
be substantiated with chiropractic research. The safest thing for
everyone to do is as follows.

  1. If you have a website, take it down NOW.

When
you have done that, please let us know preferably by email or by phone.
This will save our valuable time chasing you to see whether it has been
done.

  1. REMOVE all the blue MCA patient
    information leaflets, or any patient information leaflets of your own
    that state you treat whiplash, colic or other childhood problems in
    your clinic or at any other site where they might be displayed with
    your contact details on them. DO NOT USE them until further notice. The
    MCA are working on an interim replacement leaflet which will be sent to
    you shortly.
  1. If you have not done so
    already, enter your name followed by the word ‘chiropractor’ into a
    search engine such as Google (e.g. Joe Bloggs chiropractor) and you
    will be able to ascertain what information about you is in the public
    domain e.g. where you might be listed using the Doctor title or where
    you might be linked with a website which might implicate you. We have
    found that even if you do not have a website yourself you may still
    have been linked inadvertently to a website listing you or your
    services.

CHECK ALL ENTRIES CAREFULLY AND IF IN DOUBT, CONTACT THE RELEVANT PROVIDER TO REMOVE YOUR INFORMATION.

CHECK OUR PREVIOUS EMAILS FOR SPECIFIC ADVICE AND KEY WORDS TO AVOID.

KEEP A LOG OF YOUR ACTIONS.

  1. If
    you use business cards or other stationery using the ‘doctor’ title and
    it does not clearly state that you are a doctor of chiropractic or that
    you are not a registered medical practitioner, STOP USING THEM
    immediately.

5. Be wary of ‘mystery shopper’ phone
calls and ‘drop ins’ to your practice, especially if they start asking
about your care of children, or whiplash, or your evidence base for
practice.

IF YOU DO NOT FOLLOW THIS ADVICE, YOU MAY BE AT RISK FROM PROSECUTION.

IF YOU DO NOT FOLLOW THIS ADVICE, THE MCA MAY NOT BE ABLE TO ASSIST YOU WITH ANY PROCEEDINGS.

Although
this advice may seem extreme or alarmist, its purpose is to protect
you. The campaigners have a target of making a complaint against every
chiropractor in the UK who they perceive to be in breach of the GCC’s
CoP, the Advertising Standards Code and/or Trading Standards. We have
discovered that complaints against more than 500 individual
chiropractors have been sent to the GCC in the last 24 hours.

Whatever
you do, do not ignore this email and make yourself one of the victims.
Some of our members have not followed our earlier advice and now have
complaints made against them. We do not want that to happen to you.

Even
if you do not have a website, you are still at risk. Our latest
information suggests that this group are now going through Yellow Pages
entries. Be in no doubt, their intention is to scrutinise every single
chiropractor in the UK.

The MCA Executive has worked
tirelessly over the last week keeping abreast of development and
contacting at risk members. We have decided that this is our best
course of action to protect you and the Association at this time of
heightened tension. This advice is given to you solely to protect you
from what we believe is a concerted campaign, and does not imply any
wrongdoing on your part or the part of the Association. We believe that
our best course of action is simply to withdraw from the battleground
until this latest wave of targeting is over.

Finally, we
strongly suggest you do NOT discuss this with others, especially
patients, Firstly it would not be ethical to burden patients with this,
though if they ask we hope you now have information with which you can
respond.

Most importantly, this email and all
correspondence from the MCA is confidential advice to MCA members
alone, and should not be shared with anyone else.

Please be
aware that the office phone lines are likely to be busy, so, if you
need our help, please send an email to the office and we will get back
to you as soon as we can.

Yours,

Berni Martin

MCA Chair.

Best wishes,

Nicki


The concern expressed here is not that chiropractors might be providing misleading information to patients.  It is that groups may be documenting that information in an effort to prosecute chiropractors for making false claims to patients.  And whatever you do, chiropractors, do not discuss this with your patients:


Finally, we
strongly suggest you do NOT discuss this with others, especially
patients, Firstly it would not be ethical to burden patients with this


It certainly would not be ethical to burden patients with the realization that you are avoiding being investigated for making false claims.  That would be horrible.  I'm curious.  Ethical to whom?

The letter is no longer available at the McTimoney Association website.  Fortunately, this is the 21st century and many chiropractic websites have been archived in case they follow the letter's advice.  Well, except for the McTimoney site.  It's archive is blocked.  According to the website information, the McTimoney Association site was last modified on 8 June 2009, the same day as the letter.

Here is a comparison of the Google preview image (left) and what you get at the site (right).

Please remember to support Simon Singh in his fight against the British Chiropractic Association and the effort to keep libel laws out of scientific debate.

*Letter from The Quackometer.




Comments

logicman's picture
That should win the appeal for Simon Singh! 

Evidence suppressed by a party to a case may be taken by the court as evidence of guilty knowledge.  It may also be a contempt of court to attempt to conceal evidence supporting claim X whilst assuring the court that no evidence exists in support of claim X.   Contempt of court may be punishable by imprisonment, and is in a large part at the judge's discretion.

jtwitten's picture
Unfortunately, McTimoney and the BCA are separate entities.  The world of chiropractic is internally fractured with power grabbing going on left and right.  It is just rare to see the results of that percolate out into the public sphere.

Glad to see this is getting widespread coverage! Keep it up!

jtwitten's picture
Just following in some big footsteps.

Chiropractic is not science based. On the contrary, it has been repeatedly shown no more effective than sham placebo treatment. I thought this was a scientific blog.

jtwitten's picture
Which part did you find supportive of chiropractic?  Did you read the article and note the sarcastic tone used when referring to the chiropractors and the repeated support for Simon Singh in his court battle against chiropractors?

And, since you had a snippy tone, I feel I must point out the redundancy of saying "sham placebo" as they are redundant.

I'm a Reiki master. Reiki is not scientific either, but it works. Sham placebo refers to the action of imitating an action as compared to doing nothing (as in the sugar pill). No offense here. Chiropractic's greatist strength is that it does not rely on "hard science" as a foundation. Remember this old adage, "science is not enough. Reiki was "disproven by "science" also. Thats why people come for it. Many thanks for your comment, sorry if my intentions were misread.

I wanted to send this through the portal to let you know its really me. Sorry about the grammar. I have clients to see. Have a good day.

what a joke, this is the least scientific based information i have seen, there is more research backing up chiropractic treatment than the majority of pharmaceutical intervention, there is more research on the effects of chiropractic than aspirin!!! It repeatedly comes out on top as the preferred treatment for common conditions like low back pain, headaches, and other neuromusculoskelatal complaints. The educational system in the UK must be really lacking if this is still being argued and in courts. There are ancient chiropractors who were educated before the majority of this research was concluded, which has lead them to make erroneous claims, but they are in the minority and soon to be extinct. Evidence based education is the standard for the top chiropractic schools (western states chiropractic college, national health science university, and even Palmer). Do some research and then post something that is truly scientific. Oh yeah i'm a D.C./M.D. so i wouldn't say i am too biased in either direction

jtwitten's picture
Actually, this is a continuing news item about a libel case involving a journalist and a chiropractic association dealing with the specific claims that chiropractic can treat infections, colic, and other non-neuromuscular disorders? 

I am unaware of research that shows that chiropractic is preferred to standard physical therapy for lower back pain.  I am aware of research that shows that there is no difference.  And research that demonstrates that there are particular risks to certain chiropractic treatments.

Example references for claims?  Is that asking a lot?  I take it from your statements that you do not believe in the original rationale for chiropractic - that diseases are caused by disrupted flow of "innate intelligence" by subluxations of vertebrae?

PubMed search for
CHIROPRACTIC: 4535 articles
ASPIRIN: 43672

You'll have to explain why being a DC&an MD makes you unbiased.  Your MD in no way means that you should automatically be in opposition to chiropractic, even if it is not well evidenced.  There are plenty of MDs who support unscientific modalities out there.  Christine Northrup and Mehmet Oz come to mind.

dorigo's picture
No, you are not biased, but you sound as if you slept through your college lessons. The way you use the word "scientific" gives me the impression you do not really know what the scientific method is, nor that you care to know.

You say "There is more research on the effects of chiropractic than aspirin!".  Does that mean to you that chiropractic is a more "scientific" cure than aspirin ? If you think the consecutio holds, you do not need to be biased to be dead wrong in your conclusions.

Cheers,
T.

logicman's picture
there is more research backing up chiropractic treatment than the
majority of pharmaceutical intervention, there is more research on the
effects of chiropractic than aspirin!!! It repeatedly comes out on top
as the preferred treatment for common conditions like low back pain,
headaches, and other neuromusculoskelatal complaints.


All of which entirely misses the point: Simon Singh's remark about bogus treatments was aimed squrely at chiropractors who step outside of that box and claim to treat conditions like colic and otitis media.

I am not aware of any single test or review ever conducted by anybody at all to show that chiropractic is of any benefit whatsoever to a patient suffering from otitis media, aka chronic ear infection.  Any chiropractor who suggests that they can treat otitis media by use of their skeletomuscular manipulation skills is promoting an entirely bogus treatment for that specific condition.

there is a lot of research backing up treatment by chiropractors for otitis media and colic what everyone is failing to understand is that chiropractors don't do spinal adjustments for these symptoms/conditions. The treatment for colic is usually soft tissue mobilization and visceral adjustments designed to mobilize intestinal blockages that cause the child pain and lead to colic. The treatment for otitis media is called an eustachian pull...this is done by inserting a finger in the opening of the eustachian tube (the tube that drains the inner ear to the back of the throat... which often becomes kinked, which prevents the fluid in the inner ear from draining and leads to a stagnant breading ground for bacteria) and pulling downward to induce drainage. I am looking at my old notes from school and have multiple research studies showing that these treatments are effective and safe. So how is it not something a chiropractor can claim they can treat???

logicman's picture
The treatment for otitis media is called an eustachian pull...this is
done by inserting a finger in the opening of the eustachian tube ...

A sound piece of advice I was once given by an ear specialist:
 "Never insert anything into your ear that is smaller than your elbow."

jtwitten's picture
From a perusal of chiropractic sites that claim to treat otis media and ear infections it appears that many use neck adjustments to treat these conditions in infants.  I could find no references to the "eustachian pull" technique. 

The success rates claimed by these practices had two major issues affecting the ability of a discriminating customer to evaluate their effectiveness.  First, they were evaluated by qualitative metrics like "alleviation of discomfort", not quantitative measurements like reduction in infection titer.  Second, the rates of improvement were not compared to normal progression of recovery. 

Perhaps you could provide some of the peer reviewed references so we can evaluate the reserach?

I agree being both an MD and a DC have no extra weight when deciding bias, my point was to establish that I am not making claims in fear of losing my income. As far as scientific method being applied, the majority of the research i have read on chiropractic treatments have been double blinded, randomized, controlled studies including mock adjustments. And if you look at the most recent research and comparisons to other forms of treatment (surgery, waiting, medication) it is superior in cost effectiveness, patient satisfaction, and many other cases...i tried to find some that were done in the Uk.
"In a Randomized controlled trial, 183 patients with neck pain were randomly allocated to manual therapy (spinal mobilization), physiotherapy (mainly exercise) or general practitioner care (counseling, education and drugs) in a 52-week study. The clinical outcomes measures showed that manual therapy resulted in faster recovery than physiotherapy and general practitioner care. Moreover, total costs of the manual therapy-treated patients were about one-third of the costs of physiotherapy or general practitioner care.
-- Korthals-de Bos et al (2003), British Medical Journal"

and as far as other conditions not NMS related like asthma here are the ones i have seen

1Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database Systematic Review 2000; 2: CD001992.

2Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O'Shaugnessy D, Walker C, Goldsmith CH, Duku E, Sears MR. A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma. New England Journal of Medicine 1998; 339: 1013-1020.

3Field T, Henteleff T, Hernandez M, Martinez E, Mavunda K, Kuhn C, Schanberg S. Children with asthma improved pulmonary functions after massage therapy. Journal of Pediatrics 1998; 32(5): 854-858.

4Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. New England Journal of Medicine 1998; 339: 1021-1029.

5Chapman-Smith D. Back pain, science, politics and money. The Chiropractic Report November 1998; 12(6).

6Freeman M, Rossignol A. A critical evaluation of the methodology of a low back pain clinical trial: A case study in misleading statistics. Journal of Manipulative and Physiological Therapeutics 2000; 23(5): in press.

7Rosen M. Back pain. Report of a Clinical Standards Advisory Group Committee on back pain. May 1994, London: HMSO.

8Royal College of General Practitioners, unpublished update of CSAG Guidelines [reference 2], 1999.

9Juni P, Witschi A, Bloch R, Egger M. The hazards of scoring the quality of clinical trials for meta-analysis. Journal of the American Medical Association 1999; 282(11): 1054-1060.

10Johansen HK, Gotzsche PC, Problems in the design and reporting of trials of antifungal agents encountered during meta-analysis. Journal of the American Medical Association 1999; 282(18): 1752-1759.

11Rennie D. Fair conduct and fair reporting of clinical trials. Journal of the American Medical Association 1999; 282(18): 1766-1768.

12Gotzsche PC. Multiple publication of reports of drug trials. European Journal of Clinical Pharmacology 1989; 36: 429-432.

13Huston P, Moher D. Redundancy, disaggregation, and the integrity of medical research. Lancet 1996; 347: 1024-1026.

14Tramer MR, Reynolds DJM, Moore RA, McQuay HJ. Impact of covert duplicate publication on meta-analysis: A case study. British Medical Journal 1997; 315: 635-640.

15Sackett DL. Editorial: Evidence-based medicine. Spine 1998; 23(10): 1085-1086.

i do not perform manual treatment for asthma, colic, or otitis media.....and yes i did sleep through a lot of college courses, but they were usually literature and mathematics courses

i am also interested in knowing exactly what the curriculum in the Uk is for a chiropractor and medical doctor

jtwitten's picture
I did not mention it before, but a risk of any treatment that does not have proven efficacy is that it will divert patients from treatments with proven efficacy for their condition.

Since it is important to look at the body of research and not just individual studies (that either side of a debate can cherry pick), let's look at Cochrane systematic reviews on chiropractic for:
Asthma
The review found there is not enough evidence from trials to show
whether any of these therapies can improve asthma symptoms, and more
research is needed.

Low-Back Pain
This review of 39 trials found that spinal manipulation was more
effective in reducing pain and improving the ability to perform
everyday activities than sham (fake) therapy and therapies already
known to be unhelpful. However, it was no more or less effective than
medication for pain, physical therapy, exercises, back school or the
care given by a general practitioner.

Bed Wetting
People often use complementary methods to treat their children, but the
review of trials did not provide good evidence to support this. There
was no reliable information comparing complementary methods with
established effective methods such as alarms and desmopressin.
Complementary treatments such as hypnosis, psychotherapy, acupuncture
and chiropractic may help, but the evidence was weak.

Carpal Tunnel Syndrome
trials so far have not shown benefit from diuretics, non-steroidal
anti-inflammatory drugs, magnets, laser acupuncture, exercise or
chiropractic.

Painful Period Cramps
The review of trials found no evidence that spinal manipulation relieves dysmenorrhoea.

These are all the completed reviews I could find at the Cochrane Reviews using the search term "chiropractic".  I am not a medial practitioner, but weak evidence and "more research needed" does not seem like a solid scientific foundation for a treatment program.

sorry for the multiple posts, should have said this before, but i wanted to know what the inherent risks are for chiropractic treatment?
The one that everyone used to try to preach was that it could cause vertebro-basilar dissection, which is completely unfounded. The mechanism makes sense, but the problem that arises when doing analysis of cases is that the common symptoms associated with this condition are headaches and neck pain, which are commonly treated by chiropractors. Patients presenting with these signs and no others are often adjusted and then the full effects of the CVA is seen, but there is no cause and effect established. Resent analysis has shown you are at greater risk of suffering a stroke by seeing your general practitioner than chiropractor...which is strictly due to statistics again not cause and effect.

http://www.ncbi.nlm.nih.gov/pubmed/19251066?ordinalpos=2&itool=EntrezSys...

...which is the link you posted shows that there is no increased risk for stroke due to chiropractic treatment ???

jtwitten's picture
The authors draw that conclusion.  There is some debate about whether the data really agree with that conclusion.  While they show no significant increase in overall risk, there is increase in risk for young individuals that are otherwise at low risk for any type of stroke.  There is also debate about whether they were able to adequately distinguish different types of stroke, especially in the more elderly members of their cohort.

The beauty of science.  There is no requirement that you accept or reject papers as a whole.  One can accept the data without accepting the authors' conclusions.

Similarly, the number of studies done does not in of itself provide any evidence.  Each study must be considered in detail for its quality, which is why I cited, for my general conclusion of chiropractic's efficacy, the metastudy by the Cochrane Collaboration.

I agree with a lot of those points and use the Cochrane reviews as a point of reference many times over, and just made a donation to them. But as a medical practicioner if we limited ourselves to treatments that had solid proven evidence to dictate our treatment plans we would be very limited because in most cases we work on a trial and error method of treatment. I find myself doing this more so with medications, usually because i have been convinced by my pharmi reps that they have seen the effects in studies but they have not been concluded yet and often by the patients who have tried other treatments and not had results. The medical field does not fall within the realm of true science because no two human bodies are identical (until we start cloning) anatomy, biochemistry, etc. will all effect the outcome of the treatment. So if there is a chance it will work and has little to no risk i am likely to recommend it to a patient, which chiropractic falls into this catagory. I also support chiropractic use of physical therapy modalities over physical therapists because they have a higher level of education and are given the capabilites to diagnose and alter treatment plans when needed

jtwitten's picture
Just a few quick points:

1. I don't think the fact that your practice is not entirely dependent on chiropractic removes bias.  Some portion of your income comes from chiropractic.  Therefore, bias is unavoidable.  That kind of thing happens all the time.

2. There is a world of difference between using an unproven treatment for a condition that has no proven treatments and one where there are proven treatments.  Using an unproven treatment instead of one with known effectiveness seems unethical to me.  Oddly enough, low-back pain qualifies as one where we have no good proven treatments.  Infections, however, are one where we already do fine.

3. The humans are too individual to do science on is a frequently employed canard of th alternative medicine movement.  While we are each unique, we are not so unique that there is nothing predictable about humans.  This does not mean that everything will work for every single person all the time.  Probability may suck, but we cannot pretend it does not exist.  Science is applicable to humans and medicine.  The technical issue is getting good sample sizes. 

4. I'm not sure where to start on the "chiropractors" have more education thing.  First, years of education matter not if one is being taught made up crap like "innate intelligence" and "subluxations" like a straight chiropractic school.  Whle physical therapy is amenable to rigorous scientific research, the underlying assumptions of chiropractic do not provide a framework for understanding conditions or developing treatment in anything other than an empirical manner.

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