LOB-vs
Download Lectures on Biostatistics (1971).
Corrected and searchable version of Google books edition

Download review of Lectures on Biostatistics (THES, 1973).

Latest Tweets
Categories
Archives

Jump to follow-up

Today, 29 July 2009, a large number of magazines and blogs will publish simultaneously Simon Singh’s article. The Guardian was forced to withdraw it, but what he said must be heard (even if the word ‘bogus’ is now missing).

This is an edited version if the article in the Guardian that resulted in the decision of the British Chiropractic Association to sue Singh for libel. That decision was bad for Singh, though its effects could yet be good for the rest of the world, Firstly the decision to use law rather than rational argument stands a good chance of destroying chiropractic entirely because its claims have now come under scrutiny as never before, and they have been found wanting. Secondly, the support for Singh has been so enormous that there must now be a good chance of getting the UK’s iniquitous laws about defamation changed.

I’d rather have reproduced the original article in its entirety, but this bowdlerised version still presents the case very strongly (and the unedited version appears here and here).

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.

That’s a great account of the evidence. Notice the conclusion,

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“.

It is the job of NICE to evaluate critically that sort of thing, which makes it all the odder that the NICE guidance group, very unusually, failed to assess properly the evidence for chiropractic.

If you aren’t one of the 15,000 people who have already signed Singh’s statement, please do it now

Follow-up

Resignation of Pain Society president. While we are on the topic of chiropractic, my comment, The hidden cost of endorsing voodoo, appeared at last on the BMJ article about NICE’s low back pain guidance. The thread came back to life after the British Pain Society voted out its president, Paul Watson, a physiotherapist who was a member of the group that wrote the guidance.

Some of the links Links to some of the many repostings of Singh’s article today are aggregated at Sense about Science. There where over 200 in a single day. The British Chiropractic Association tried to suppress criticism, but they clearly don’t understand the web.

An intrepid, ragged band of bloggers. Chiropractors may regret choosing to sue Simon Singh, springing online scientists into action”. Ben Goldacre has summed up the reaction of the blogosphere with characteristically fine style in the Guardian.  Ragged? Moi? The blog version (with links) is here.

Print Friendly, PDF & Email

14 Responses to Simon Singh on chiropractic: “Beware the spinal trap”

  • Dear Prof

    I read your rapid response in eBMJ (the hidden cost of endorsing voodoo medicine). I think we are all agreed that alternative medicine is big business. One only has to read Singh/Ernst’ book ‘Trick or Treatment’ to see how mind boggling the figures are.

    However, I think another aspect of alternative medicine that is sometimes overlooked is the financial value of diagnosis (which I accept is tied in with treatments).

    Take low back pain. According to Waddell (1) it is only possible to diagnosis 15% of all back pain cases (and some would assume this is generous). How easy it is then to fill the void with spurious diagnoses, such as an uneven pelvis, subluxed this or that, or having several discs out of place.

    The therapeutic value of a diagnosis is, I am sure you would agree, often more potent that any treatment that follows. Even a placebo diagnosis (i.e. one entirely made up) will have some short term value, although lying to patients is clearly not on.

    However inaccurate diagnoses are as potentially damaging to the patient’s health as inappropriate treatments. They confuse the patient and ultimately leads to despondency and a worsening of symptoms. Patients having run through a gamut of alternative explanations are often too battle weary or suspicious of less glamorous diagnoses provided by conventional doctors (such as we don’t know)

    A chiropractor colleague in Oxford gets as exasperated as anyone when he hears his peers peddling dodgy diagnoses (in particular the subluxation theory). He believes it is the competitive business model that chiropractors and other private therapists work within which encourages this behaviour.

    I respond by pointing out the thousands of physiotherapists who do exactly the same thing within the NHS. Greed may be a factor, but a lack of basic scientific rigour is most likely the biggest cause.

    Perhaps Singh and Ernst should explore the fantasy diagnosis industry.

    Malucachu (Welsh for b*llsh*t – a useful word in this context)

    1. Waddell G: The Back Pain Revolution. Chruchill Livingstone 1998

  • @malucachu
    So that is what your pseudonym means! Very appropriate.

    I think you are dead right about bogus diagnosis being as dangerous, and as cruel, as bogus treatment. In fact the biggest problem with the NICE guidance was, I thought, an unwillingness to admit openly that in most cases of low back pain no diagnosis is possible and no effective treatment exists. To fail to admit that you don’t know is, I suppose, a form of medical arrogance. It is universal among quacks but it exists everywhere. It impedes progress and, in the end, it harms patients.

    Another form of the same phenomeno is found in the vigorous marketing of private “executive health checks“, which only too often lead to false alarms and unnecessary prescriptions.

  • Another form of the same phenomenon is found in the vigorous marketing of private “executive health checks”, which only too often lead to false alarms and unnecessary prescriptions.

    According to my medical friends, the modern high-tech (and expensive) version of this scam involves unnecessary whole body MRI and/or CT scans, which then show “incidentalomas” that need to be investigated, at additional expense and often to no-one”s benefit.

    Via a comment on this post over at Dr Crippen’s blog, I discover there is a new acronym for people in this situation: VOMIT (Victims of Modern Imaging Technology).

  • Dr Aust. Thanks for those fascinating links. Oddly enough, I just found myself facing the VOMIT dilemma. My recent DVT is resolving nicely, but the CT scans that followed it revealed a ‘small renal mass’ (<3 cm) in my left kidney. I’ll probably have to decide whether to go for partial or complete nephrectomy, but I’m not unduly worried. The prognosis looks really good (Sanchez-Martin et al, 2008), Silverman et al, 2008)

  • Just out of curiosity: how much evidence is there from prospective, randomized, double-blind, controlled clinical trials is there that physiotherapy is an effective remedy for lower back pain?

  • @FrankO
    As far as I know, very little. It’s hard to see what control you could use that would be blind. What the evidence does say is that there is no detectable difference in effectiveness between physiotherapy, osteopathy and chiropractic. It could perfectly well be the case that none of them work at all.

    All I was saying is that, if you want to try manipulation, it might just as well be physiotherapy, not because it is known to be better, but simply because it is free of quasi-religious gobbledygook that makes chiropractic and osteopathy unacceptable in the 21st century.

  • FrankO: the answer is none. And don’t be so sure DC that physiotherapy is free of gobbledegook. We might not go so far into believing in ‘life forces’, but look at any debate on how back pain patients are managed and the mind boggles at some of the clinical decision making processes that PTs come up with (e.g. the much over-used sacro-iliac lesion).

    Contrast that with the extensive knowledge and hugely impressive skills of PTs working in neurology, an area of medical rehabilitation starved of funds. Stopping NHS PTs providing acupuncture for back pain patients could divert essential funds for patients with profound disabilities, such as a stroke or Parkinson’s’ disease.

Leave a Reply