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The publication of Gilbey’s paper and my editorial in the New Zealand Medical Journal (NZMJ) led to a threat of legal action by the NZ Chiropractors’ Association Inc for alleged defamation.  After publishing a defiant editorial, the editor of the NZMJ offered chiropractors the chance to put their case.

In the last issue of NZMJ (22 Aug 2008) three letters appeared. One was from Brian Kelly, (President, New Zealand College of Chiropractic) [download letter]. One was from Karl Bale (CEO/Registrar, Chiropractic Board New Zealand) [download letter], and one was from Simon Roughan (Registered Chiropractor and Acting President of the New Zealand Chiropractors’ Association) [download letter].

In the current issue (5 September 2008) Gilbey, Ernst and I responded.{download Gilbey response] [download Ernst response].

Here’s mine. The printed version differs in minor ways [download pdf]

I’m grateful for the opportunity to reply to the defences of chiropractic from Kelly1, Roughan2 and Bale3 in your last issue.

I’d like first to deal with the minor matter of titles, before getting on to the more important question of  vidence. I notice that Brian Kelly signs his letter “Dr Brian Kelly B App Sci (Chiro)” in his letter to NZMJ. He seems to be a bit less careful in his use of titles on his own school’s web site where his president’s welcome4 is signed simply “Dr Brian Kelly”, a title he adopts in at least three other places. Karl Bale3 (CEO/Registrar, Chiropractic Board New Zealand) points out that “Failure to qualify the use of the title ‘Doctor’ may contravene the provisions of the Medical Practitioners Act 1995”. One wonders whether Bale has done anything to stop Kelly’s apparent breaches of this rule?

This example makes on wonder whether the Chiropractic Board take its responsibilities seriously? It seems often to be the case that ‘voluntary self-regulation’ doesn’t work, because there are too many vested interests. Karl Bale points out that some ruthless sales methods characteristic of chiropractic are also contrary to the Chiropractic Board’s code of ethics. One would hope their well-known antipathy to vaccination and to medicine as a whole were also considered unethical. These practices seem to continue so the the code of ethics
seems not to be enforced. Much the same is true in other forms of alternative medicine too5.

It seems to me quite remarkable that none of the letters mentions the ‘subluxation’ that lies at the heart of their subject6. Could that be because they are reluctant to admit openly that it is a mere metaphysical concept, that no one can see or define? It is sad that so many patients are subjected to X-rays in search of this  phantom idea. It is this metaphysical nature of chiropractic that separates it quite clearly from science.

Brian Kelly says “How can any reader take seriously, anything suggested by a writer who opines that a 19th Century journalist possessed superior “intellectual standards” to “the UK’s Department of Health” and “several university vice chancellors”. The views of the Davenport Leader on chiropractic were mild compared with those of the great H.L. Mencken (1924)7 who wrote “This preposterous quackery flourishes lushly in the back reaches of the Republic, and begins to conquer the less civilized folk of the big cities….” The problem is that the Department of Health is full of arts graduates who may be very good at classics but can’t understand the nature of evidence. And the UK has one vice-chancellor, a geomorphologist, who defends a course in his university that teaches that “amethysts emit high yin energy”8 I’ll admit, though, that perhaps ‘intellect’ is not what’s deficient in this case, but rather honesty.

Your correspondents seem to confuse the duration of a course with its intellectual content. You can study homeopathy for years too, but after all that they are still treating sick people with medicines that contain no medicine. Anyone who works in a university knows that you can easily get accreditation for anything whatsoever if you choose the right people to sit on the committee. I have seen only too many of these worthless pieces of paper. “Amethysts emit high yin energy”8 was part of an accredited course (at the University of Westminster) too. Need I say more?

Now to the real heart of the problem, namely the question of evidence. Brian Kelly says that the book by Singh and Ernst9 shows “extreme bias”, but what that book actually shows is an extremely scrupulous regard for evidence, Ernst is in a better position to do this than just about anyone else. He has qualified and practised both regular and alternative medicine, and he was appointed to his present position, as professor of complementary and alternative medicine to assess the evidence. Perhaps most importantly of all, his position allows him to do that assessment with complete lack of bias because, unlike Kelly, his livelihood does not depend on any particular outcome of the assessment. I’m afraid that what Kelly describes as “extreme bias” is simply a display of pique because it has turned out that when all the evidence is examined dispassionately, the outcome is not what chiropractors hoped.

The fact of the matter is that when you look at all of the evidence, as Singh & Ernst do, it is perfectly clear that chiropractic is at best no better than conventional treatments even for back pain. For all other conditions its benefits fail to outweigh its risks – contrary to the many claims by chiropractors. Both the New Zealand and the UK governments have got themselves into an impossible position by giving official recognition to chiropractic before the evidence was in. Since the conventional manipulative treatments are cheaper, and may be well be safer, and because they involve no quasi-religious ideas like “subluxation” or “innate intelligence”, the only reasonable conclusion is that there is no need for chiropractic to exist at all. They do nothing they do that could not be done as well by medical practitioners and physiotherapists. What will governments do about that, I wonder?

David Colquhoun

1. Kelly, B. New Zealand College of Chiropractic response to
“Dr Who?” editorial.
NZMJ 22 August 2008, Vol 121 No 1280

2. Roughan, S. Setting the record straight: New Zealand Chiropractors’ Association response letter. NZMJ 22
August 2008, Vol 121 No 1280

3. Bale,
K. Chiropractic Board New Zealand response to “Dr Who?” editorial.
NZMJ 22
August 2008, Vol 121 No 1280.

4. http://www.nzchiro.co.nz/about_president.php

5. http://dcscience.net/?p=24

6. http://www.chirobase.org/01General/chirosub.html

7. http://www.geocities.com/healthbase/mencken_chiro.html

8. http://dcscience.net/?p=227

9. Singh S, Ernst E. Trick or Treatment. Bantam Press; 2008

The wars within chiropractic

Although the chiropractors seem to be rather upset by the criticisms that have been levelled against them, the most interesting war is not between chiropractors and people who think that medicine should not be based on metaphysics.  It’s the war within chiropractic itself.

The internecine wars within chiropractic have been going almost from the day it was invented.  The (ex-)insider’s view gives us a rare insight into what chiropractic schools actually do.   Now support has come from a rather unexpected quarter.  An article by five chiropractors has just appeared by Murphy et al. (Chiropractic & Osteopathy, 2008, 16:10).

Although the authors declare that they have “a financial interest in the success” of chiropractic, the changes that they propose are so drastic that, if implemented, tthey would leave little left to distinguish chiropractic from, say, physiotherapy. The authors ask the very pertinent question, ‘why is it that podiatry (chiropody in the UK) is well accepted and chiropractic remains on the controversial fringe of medicine?..   Here are some quotations.

“It is also vital that those chiropractors who dogmatically oppose common public health practices, such as immunization [15] and public water fluoridation, cease such unfounded activity.”

“We are concerned that the common perception (which is well supported, in our experience) that chiropractors are only interested in “selling” a lifetime of chiropractic visits may be one of the primary factors behind our low standing in the minds of members of the public [2].”

“One of the problems that we encounter frequently in our interaction with chiropractic  educational institutions is the perpetuation of dogma and unfounded claims. Examples include the concept of spinal subluxation as the cause of a variety of internal diseases and the metaphysical, pseudo-religious idea of “innate intelligence” flowing through spinal nerves, with spinal subluxations impeding this flow. These concepts are lacking in a scientific foundation [27] [28] [29] and should not be permitted to be taught at our chiropractic institutions as part of the standard curriculum. Much of what is passed off as “chiropractic philosophy” is simply dogma [30], or untested (and, in some cases, untestable) theories [27] which have no place in an institution of higher learning, except perhaps in an historical context.”

“The Council on Chiropractic Education requirement of 250 adjustments forces interns to use manipulation on patients whether they need it or not, and the radiographic requirement forces interns to take radiographs on patients whether they need them or not.”

“They [podiatrists] did not invent a “lesion” and a “philosophy” and try to force it on the public. They certainly did not claim that all disease arose from the foot, without any evidence to support this notion. The podiatric medical profession simply did what credible and authoritative professions do [32] – they provided society with services that people actually wanted and needed.”

“In the beginning, DD Palmer invented a lesion, and a theory behind this lesion, and developed a profession of individuals who would become champions of that lesion. This is not what credible professions do.”

“In the interim it [chiropractic] has seen its market share dwindle from 10% of the population [4] to 7.5% [3] [42]. Even amongst patients with back pain, the proportion of patients seeing chiropractors dropped significantly between 1987 and 1997, a period of time in which the proportion seeing both medical doctors and physical therapists increased [43].”

“When an individual consults a member of any of the medical professions, it is reasonably expected that the advice and treatment that he or she receives is based in science, not metaphysics or pseudoscience.”

“The chiropractic profession has an obligation to actively divorce itself from metaphysical explanations of health and disease as well as to actively regulate itself in refusing to tolerate fraud, abuse and quackery, which are more rampant in our profession than in other healthcare professions [46].”

“Podiatric medicine is a science-based profession dedicated to the diagnosis and treatment of foot disorders. Foot reflexology is a metaphysically-based group consisting of non-physicians who believe that many physical disorders arise from the foot. Podiatrists have rejected foot reflexology as an unproven and unscientific practice, and do not consider it part of mainstream podiatric practice.”

“We must finally come to the painful realization that the chiropractic concept of spinal subluxation as the cause of “dis-ease” within the human body is an untested hypothesis [27]. It is an albatross around our collective necks that impedes progress.”

All this, remember, comes from five chiropractors. That looks like all out war between their view of chiropractic and that taught in New Zealand College of Chiropractic, and, in the UK by the three chiropractic colleges in the UK.

Follow-up

A report in the New Zealand Herald (18 September 2008) is rather relevant to all this.

Chiropractor to apologise after patient has stroke

A chiropractor has been recommended to apologise to a woman patient who suffered a stroke after he treated her.

The case report is here.

The Advertising Standards Authority has had a bit to say about chiropractors too.


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22 Responses to Chiropractic wars. Part 3: internecine conflict

  • The burgeoning ideological conflict within chiropractic profession is fascinating and may well be a test case of how CAM proponents deal with their evidence base. I suspect it will get messy as I can’t help but think the reasoning outlined by Murphy et al. for purely evidence based practice effectively abolishes chiropractic and turns it into no more than a subset of physiotherapy.
    Almost all CAM practitioners, of any type, are reflexively anti evidence based health care in their response to public health measures such as vaccination or invasive, but effective, treatments for cancer. For them to build a profession on evidence would require them to be accepting of the evidence for modern medical practice and I am almost certain that this they will not do. This chiropractic war may prove to be nothing but a diversion.

  • Great riposte DC, if a little strongly worded (I’m not suggesting that you tone down your letters, just that in an industry that’s refractory to criticism at the best of time I’d doubt your stance would be well-received). Whilst watching CAMsters tearing down their castle from the inside is good sport, I’m with Gimplblog on this one – it’s far likelier that the dissenters will be cast asunder whilst the industry goes on cracking backs and peddling myths, rather than the practices being denounced disappearing. Here’s hoping I’m wrong tho…!

  • Agree with Teek that the likely riposte from the greater mass of new age / mystic back-crackers will be to cast out the “Evidence Five” and anyone who agrees with them. However, suppose the NHS, and the NZ medical authorities, were to state flatly that they would not employ, or allow referrals to or recommendations of, ANY “metaphysical school” chiropractors? Or – even better, though vanishingly unlikely – suppose Ofquack were to have the balls to say that henceforth only evidence-based spinal manipulation therapies should be allowed “health practitioner” status? That would then put a financial incentive on both sides of the argument.

    It is not impossible to try and put CAM therapies on an evidence-based footing. That is what Edzard Ernst has been trying to do. It would even be possible to DISCUSS the metaphysical philosophy with the punters as “metaphor” without dishonesty – provided the practitioners can tell the difference. [This is the kind of way that alternative therapies are often done in, say, Germany, where the practitioners are mostly conventionally-trained doctors.] It is the chiropractors (and others) clinging to, teaching, and promulgating, superstitions as “received and revealed truth” that is the problem.

    The reason why it is important that people within these “professions” say this, as well as skeptics, is precisely to make the point that even some of the pracititioners see that it could be done (and patients retain “choice”) without the obligatory superstition. In the modern political climate it is going to be incredibly difficult to get ANY Govt. to take a measure that is seen to “restrict “choice””, including in (Alt) health. Tony Blair was very upfront about this and I think most politicians think the same way in varying degrees. But if you present them with:

    “Yes, patients can have their choice of Alt Therapy, but they can have the proper evidence-based version of that choice, or the away-with-the-fairies proffered-by-nutters version”

    – then you have a chance.

  • I’ve been following your “war” on chiropractics with some interest. While I am all for exposing the frud of “alternative medicine”, I’m also for playing honest.

    Several times you’ve made claims that chiroprators claim they are an alternative to vaxination, and that they believe in metaphysical concepts like subluxation.

    This is false.

    It is true that some chiroprators do this, but it is false that chiropractors as a whole, or in general, do.

    My problem with your “war” is not that you attack those chiropractors that do promote such nonsense, but that you are spreading the misinformation that chiropractors in general are operating like this. From my experience this is far from the truth.

    So I would suggest that if you continue making such claims, you should back them up with evidence. Do you have access to any infomration/research showing how large percentage of the chiropractics are making such claims?

    You do attack others for not being honest and making claims without evidence. But in this case you’re unfortunatly not much better yourself.

    Don’t attack chirpractors in general for what a few of them do. Attack the few who do this, or the organisations who allow this from their members. I do support your war against pseudomedicine and pseudoscience. But please be honest yourself, don’t make false claims about chiropractors in general, and don’t attack all of them for what a few of them do.

  • Good to know that there are some chiropractors who do seek truth and evidence.

    However I am puzzled. If the original raison d’etre of chiropractic is based on the false assumptions of subluxations etc., is there any need for them at all? Why not, if it is really necessary, just broaden the physiotherapy base, and have everything under the evidence-based banner in the first place?

  • JM. Clearly my comments were aimed only at those who do advise against vaccination. According to Murphy et al. (all chiropractors themselves) that is a real problem and the paper they cite, Russell et al. (2004), gives some numbers. See also here.

  • I feel as though I might have found someone with similar views…maybe CAM change is a reality? Maybe, just maybe, there will be enough resistance to ‘philosophy lead practice’…what am I saying? Who am I kidding – it will be me, a few chiropractors in the US and possibly a few others that have yet to dare to put their head above the trenches!

    Regardless – CAMs criticising CAMs are to be encouraged.

    JH

  • Slightly off topic: There is currently a consultation on the Dept of Health website about ‘The General Chiropractic Council (Constitution) Order 2008’, described thus: “This draft order sets out a proposed constitution for the GCC. It provides details of the composition of the council, the terms of office of council members, and criteria for the disqualification, suspension or removal of members from office.”

    I wondered if anyone had any suggestions for appropriate responses to this uninspiring document?

    The closing date for responses is 3 October 08.
    http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_086209

  • I am pleased to see chiropractic compared to podiatry. I have made the same comparison in the same unfavourable way (to chiropractic). I think the comparison to be an apposite one.

    The lives of many diabetic and elderly people would be very much worse with the work that podiatrists do. Very much of their work consists of treating diabetic ulcers, corns, bunions and other utterly unglamorous yet deblilitating conditions.

    I ask my podiatrist simply to diagnose, measure and correct those aspects of my anatomy that are incompatible with my chosen sport. The blisters I deal with myself.

    I hold podiatrists in the same esteem as physiotherapists, the latter have given me back the use of various bits of me after I have abused them in a manner professional and quietly competent, yet never without regard to the risks or likelihood for success of the treatment.

    Though one did get exasperated with me after I presented my third inversion sprain. ‘Stay off the trails’ he told me. So I did and turned the 4th (two on each ankle) on a kerbstone. He treated that one stoicly…

    Crepuscle the best response will be to ask what measures can and will be taken to prevent chiropractors removed from the roll from simply reinventing themselves and carrying on as before. Without such a measure any such sanction is toothless. A medical doctor or nurse cannot practice if so censured by their professional bodies and there are statutory strictures against it. Why not chiropractors if they have similar regulation?

  • crepuscule,

    The consultation is happening in my profession too. Basically, the ‘council’ of the councils is currently made up of a majority of members of that profession, elected by that profession. The government have made a move to appoint only 50% of that profession as council members by an independent body. It SHOULD make it more objective as a council!

    We’ll see…

  • A hugely informative post, not least because of all the various New Zealand Medical Journal pdfs which wouldn’t normally be available to most readers for another six months.

    David Colquhoun wrote in his response to Kelly, Roughan and Bale: “Since the conventional manipulative treatments are cheaper, and may be well be safer, and because they involve no quasi-religious ideas like “subluxation” or “innate intelligence”, the only reasonable conclusion is that there is no need for chiropractic to exist at all. They do nothing they do that could not be done as well by medical practitioners and physiotherapists.”

    Interestingly, that’s similar to the conclusion which the well-respected veteran American chiropractor, Samuel Homola, reached in this 2006 article:

    Quote:

    “As I warned in ‘Bonesetting, Chiropractic and Cultism’, if chiropractic fails to specialize in an appropriate manner, there may be no justification for the existence of chiropractic when there are an adequate number of physical therapists providing manipulative therapy. Many physical therapists are now using manipulation/mobilization techniques…..It matters little who does spinal manipulative therapy as long as it is appropriate and evidence-based.”

    http://jmmtonline.com/documents/HomolaV14N2E.pdf

    And it’s a prospect that seems to be causing more than a little concern in some chiropractic quarters. For example, in an article which was published in the current edition of ‘The Chiropractic Journal’, the president of the (subluxation-based) World Chiropractic Alliance (WCA), Terry A. Rondberg DC, made this pessimistic prediction:

    Quote:

    “I am convinced that we will never survive as a separate profession if we position ourselves as a quasi-medical therapy for musculoskeletal conditions. Even Dr. Herring [Charles Herring, DC, President of the Foundation for Chiropractic Education and Research (FCER)] admits that: “… there is increasing competition between the chiropractic profession and the physical therapists. They have established doctoral programs and are doing a significant amount of research in universities. There is even talk in Washington that chiropractic should be considered a subset of physical therapy since PTs are more integrated into the education system and the medical treatment model. We are currently in a race to have cultural authority over manipulation, but when it comes to research to support this authoritative position we are losing the race.””
    http://www.worldchiropracticalliance.org/tcj/2008/sep/rondberg.htm

    So, even if some pretty radical changes were to be made, it looks like chiropractic will still face a struggle to survive in the long-term.

    For anyone interested in learning more, especially about why it might not be a good idea to train to become a chiropractor in this day and age, you’ll find just about all you need to know on the skeptical chiropractic discussion forum ‘Chirotalk’:
    http://chirotalk.proboards3.com/

  • Table 2 in the Russell et al paper is revealing. Depressingly so – 48.1% of respondents disagree that vaccinations are generally safe and while 56.1% believe they weaken the immune system, 53.2% believe that vaccinations can cause autism. 57.9% agree that “it is better to be naturally infected (get the disease) than to be vaccinated”.

    These figures certainly do not suggest that JM is correct in his assertion that it is “only a few” chiropractors that are posing a problem.

    The numbers relating to whether doctors, nurses, fellow chiropractors and patients think the respondents should counsel their patients about immunisation are interesting too. [Roughly three times as many chiropractors as MDs think the respondent should counsel patients on this matter]

  • Thank you Professor Colquhoun and all the other contributors who have helped me to become aware of what chiropractors are actually about. Like many others, I had only the vaguest idea of what they did, and why they did it, and had thought them to be practitioners of some sort of specialist physiotherapy.

    A chiropractor was recommended to my wife by her boss, a former body-builder, who qualified his recommendation by telling us that the chiro being recommended had treated several well-known footballers and other famous sports personalities.

    Thanks to you, and the various links provided, I was able to steer my wife towards practitioners of evidence-based medicine who promptly and successfully treated her condition.

    Your work is of inestimable value, and I don’t hesitate to direct those of innocent ignorance toward this site and the many other sites I have been made aware of here.

    Good on you!

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