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Chiropractors are getting very touchy indeed, all over the world. And no wonder, because their claims are being exposed as baseless as never before, in the wake of their attempts to stifle criticism by legal action..

In March, Shaun Holt appeared on Breakfast TV in New Zealand. Holt has done a lot of good work on TV in debunking some of the preposterous claims made by quacks. See him on YouTube.

This time he talked about chiropractic. Here is the video.

One could argue that he was over generous to chiropractic, especially when talking about their effectiveness in treating low back pain. He said, quite rightly, that chiropractors are no better than physiotherapists at treating low back pain.

But a recent trial suggests that neither are much good. “A randomised controlled trial of spinal manipulative therapy in acute low back pain” (Juni et al., 2009 in the BMJ; see also coverage in Pulse). This trial compared standard care with standard care plus spinal manipulative therapy (SMT). The results were negative, despite the fact that this sort of A + B vs B design is inherently biassed in favour of the treatment (see A trial design that generates only ”positive” results, Ernst & Lee 2008, Postgrad Med J.).

"SMT was performed by a specialist in manual medicine, chiropractice and rheumatology (GH), a specialist in physical medicine (DV) or an osteopath (RvB), all proficient in SMT."

"Conclusions: SMT is unlikely to result in relevant early pain reduction in patients with acute low back pain."

Admittedly, the trial was quite small (104 patients, 52 in each group) so it will need to be confirmed. but the result is entirely in line with what we knew already.

It also adds to the evidence that the recommendation by NICE of SMT by chiropractors constitutes their biggest failure ever to assess evidence properly. If NICE don’t amend this advice soon, they are in danger of damaging their hitherto excellent record.

Despite the moderate tone and accuracy of what Holt said on TV, the New Zealand Chiropractors’ Association made a formal complaint. That is what they like to do, as I learned recently, to my cost. It is so much easier than producing evidence.

Quite absurdly the New Zealand Broadcasting Standards Authority (BSA) has upheld some of the complaints. Their judgement can be read here.

The BSA consists of four people, two lawyers and two journalists. So not a trace of scientific expertise among them. Having people like that judging the claims of chiropractors makes as much sense as having them judged by Mr Justice Eady. They seem to be the sort of people who think that if there is a disagreement, the truth must lie half-way between the opposing views.

One of the BSA members, Tapu Misa, has used her newspaper column to quote approvingly the views of the notorious Dr Mercola web site on flu prevention “Your best defence, it says, is to eat right, get lots of sleep, avoid sugar and stress, load up on garlic, Vitamin D and krill oil”. (Snake oil is said to be good too.)    There are some odd attitudes to science in some of her other columns too (e.g. here and here). Not quite the person to be judging the evidence for and against chiropractic, I think.

In fact the TV show in question was more than fair to chiropractors. It adopted the media’s usual interpretation of fair and balanced: equal time for the flat earthers. A Chiropractor was invited to reply to Holt’s piece.  Here he is.

The chiropractor, Doug Blackbourn, started very plausibly, though a tendency to omit every third syllable made transcription hard work. He established that if you cut yourself you get better (without any help). He established that nerves run down the spinal cord. So far, so good. But then he quickly moved on to the usual flights of fancy.

"We have two premises. The body heals itself and the nervous system runs the body. Now the nervous system runs the body, travels down through the spinal cord so chiropractic is not based on the belief that, you know, energy flows, it’s based on the fact that your nervous system runs the body and [inaudible] affects the overall health of the body"

This statement is totally vague. It has nothing whatsoever to do with the main question, can chiropractors do anything useful. It is sheer flannel.

We’re seeing people, heck, diabetes. I had a quadriplegic come in one time for adjustment, we’ve got stroke people, we’ve got all sorts of conditions. We’re not treating the condition, We’re allowing, checking the spine to see if there’s any interference there that will slow the body down"

“Interference”? “slowing the body down”? These are utterly meaningless phrases that simply serve to distract from the only question that matters.

"Chiropractice is the most safest [sic] profession to go to to get your spine adjusted"

Hmm I thought it was the only job that uses the word ‘adjustment’.

Worst of all was his response to a question about asthma.

Presenter: "So chiropractors are not out there claiming they will cure asthma for example?". Chiropractor: "No"

This is simply untrue, both in New Zealand and in the UK. For a start, just look at what Blackbourn’s own web site says about asthma.

"The challenge, of course, with allergy and asthma medication is there is no end-point. There is no cure. Asthma and allergies, for the most part, are lifelong conditions requiring lifelong medication. Might there be a better way, an alternative solution?

“Alternative” is the key word. Medical treatment is designed to combat symptoms, and is successful to a certain extent with allergies and asthma. Underlying causes are not addressed, however, and symptoms continue year after year. What else might be done?

Enter chiropractic care. Chiropractic health care, with its unique comprehensive approach, is able to offer positive benefit to a variety of conditions and ailments. In the case of allergies and asthma, these “hypersensitivity conditions” may respond well to therapy designed to normalize the body’s flow of nerve signals. To use a metaphor, chiropractic treatment removes roadblocks to the body’s natural healing abilities. Restoring these imbalances may help reduce such hypersensitivity reactions."

Blackbourn’s web site describes him thus

"As a Doctor of Chiropractic, Dr. Doug Blackbourn . . ."

But the qualifications of “Dr” Blackbourn are B.App.Sc (Chiro) M.N.Z.C.A , the same as those of “Dr” Brian Kelly.

After a performance like this, perhaps someone should submit a complaint to the New Zealand Broadcasting Standards Authority.

After all, I notice that they have dismissed complaints from one chiropractor, Sean Parker, after a TV programme looked at the business practices of his private chiropractic practice, The Spinal Health Foundation. Perhaps the BSA understands business better than it understands science.

### Follow-up

Is chiropractic crumbling in New Zealand? The New Zealand College of Chiropractic featured in my editorial in the New Zealand Medical Journal, and in the fallout from that article, It’s principle, “Dr” Brian Kelly (B App Sci (Chiro)) seems to be getting desperate. His college is now canvassing for recruits in Canada. They are promised all the woo.

• Subluxation centered techniques – Gonstead, Toggle Recoil, Thompson, Diversified
• Traditional philosophy featuring vitalism and innate healing – congruent curriculum

Perhaps Canada is a good place to recruit, gven the $500 million class action being brought against chiropractors in Canada, after Sandra Nette became tetraplegic immediately after a chiropractor manipulated her neck, Canadian chiropractors must be looking for somewhere to hide. Stuff and Nonsense. jdc described this story at the time the complaint was lodged. Shaun Holt’s own blog follows the action. New Zealand Doctor covers the story. Bay of Plenty TimesBay researcher slams television complaint ruling Jump to follow-up In July 2008 I wrote an editorial in the New Zealand Medical Journal (NZMJ), at the request of its editor. The title was Dr Who? deception by chiropractors. It was not very flattering and it resulted in a letter from lawyers representing the New Zealand Chiropractic Association. Luckily the editor of the NZMJ, Frank Frizelle, is a man of principle, and the legal action was averted. It also resulted in some interesting discussions with disillusioned chiropractors that confirmed one’s worst fears. Not to mention revealing the internecine warfare between one chiropractor and another. This all occurred before the British Chiropractic Association sued Simon Singh for defamation. The strength of the reaction to that foolhardy action now has chiropractors wondering if they can survive at all. The baselessness of most of their claims has been exposed as never before. No wonder they are running scared. The whole basis of their business is imploding. Needless to say chiropractors were very cross indeed. Then in February 2009 I had a polite email from a New Zealand chiropractor, David Owen, asking for help to find one of the references in the editorial. I’d quoted Preston Long as saying "Long (2004)7 said “the public should be informed that chiropractic manipulation is the number one reason for people suffering stroke under the age of 45. And I’d given the reference as 7. Long PH. Stroke and spinal manipulation. J Quality Health Care. 2004;3:8–10 I’d found the quotation, and the reference, in Ernst’s 2005 article, The value of Chiropractic, but at the time I couldn’t find the Journal of Quality Healthcare. I did find the same article on the web. At least the article had the same title, the same author and the same quotation. But after finding, and reading, the article, I neglected to change the reference from J Quality Health Care to http://skepticreport.com/sr/?p=88. I should have done so and for that I apologise. When I asked Ernst about the Journal of Quality Healthcare, he couldn’t find his copy of the Journal either, but he and his secretary embarked on a hunt for it, and eventually it was found.  It turns out that Journal of Quality Healthcare shut down in 2004, without leaving a trace on the web, or even in the British Library. It was replaced by a different journal, Patient Safety and Quality Healthcare (PSQH) A reprint was obtained from them. It is indeed the same as the web version that I’d read, and it highlighted the quotation in question. The reprint of the original article, which proved so hard to find, can be downloaded here. The full quotation is this "Sixty-two clinical neurologists from across Canada, all certified members of the Royal College of Physicians and Surgeons, issued a warning to the Canadian public, which was reported by Brad Stewart, MD. The warning was entitled Canadian Neurologists Warn Against Neck Manipulation. The final conclusion was that endless non-scientific claims are being made as to the uses of neck manipulation(Stewart, 2003). They need to be stopped. The public should be informed that chiropractic manipulation is the number one reason for people suffering stroke under the age of 45." I have often condemned the practice of citing papers without reading them (it is, of course, distressingly common), so I feel bad about this, though I had in fact read the paper in question in its web version. I’m writing about it because I feel one should be open about mistakes, even small ones. I’m also writing about it because one small section of the magic medicine community seems to think they have nailed me because of it. David Owen, the New Zealand chiropractor, wrote to the editor of the NZMJ, thus.  The quote [in question] is the public should be informed that chiropractic manipulation is the number one reason for people suffering stroke under the age of 45. Long PH. Stroke and Manipulation. J Quality Health Care. 2004:3:8-10 This quote actually comes from the following blog article http://www.skepticreport.com/medicalquackery/strokespinal.htm [DC the URL is now http://skepticreport.com/sr/?p=88] I have attached all my personal communications with Colquhoun. They demonstrate this is not a citation error. Prof Colquhoun believes the origin of the quote doesn’t matter because Long was quoting from a Canadian Neurologists’ report (this is also incorrect). As you can see he fails to provide any evidence at all to support the existance [sic] of the “J Quality Health Care.” This would not be an issue at all if he had admitted it came from a blog site— but I guess the link would have eroded the credibility of the quote. Colquhoun ‘s belief that my forwarding this complaint is me “resorting to threats” is the final nail in the coffin. If he had any leg to stand on where is the threat? This may seem pedantic but it surely reflects a serious ethical breach. Is it acceptable to make up a reference to try and slip any unsupported statement into a “scientific” argument and thereby give it some degree of credibility? Incidentally, at the end of the article, conflicts of interest are listed as none. As Colquhoun is a Professor of Pharmacology and much of his research funding no doubt comes from the pharmaceutical industry how can he have no conflict of interest with therapies that do not advocate the use of drugs and compete directly against the billions spent on pain medications each year? If I may quote Colquhoun himself in his defence of his article (Journal of the New Zealand Medical Association, 05-September-2008, Vol 121 No 1281) I’ll admit, though, that perhaps ‘intellect’ is not what’s deficient in this case, but rather honesty. David Owen ### Financial interests Well, here is a threat: I’m exposed as a shill of Big Pharma. ". . . much of his funding no doubt comes from the pharmaceutical industry". I can’t count how many times this accusation has been thrown at me by advocates of magic medicine. Oddly enough none of them has actually taken the trouble to find out where my research funding has come from. None of them even knows enough about the business to realise the extreme improbability that the Pharmaceutical Industry would be interested in funding basic work on the stochastic properties of single molecules. They fund only clinicians who can help to improve their profits, The matter of funding is already on record, but I’ll repeat it now. The media ‘nutritional therapist’, Patrick Holford, said, in the British Medical Journal “I notice that Professor David Colquhoun has so far not felt it relevant to mention his own competing interests and financial involvements with the pharmaceutical industry “ To which my reply was ” Oh dear, Patrick Holford really should check before saying things like “I notice that Professor David Colquhoun has so far not felt it relevant to mention his own competing interests and financial involvements with the pharmaceutical industry”. Unlike Holford, when I said “no competing interests”, I meant it. My research has never been funded by the drug industry, but always by the Medical Research Council or by the Wellcome Trust. Neither have I accepted hospitality or travel to conferences from them. That is because I would never want to run the risk of judgements being clouded by money. The only time I have ever taken money from industry is in the form of modest fees that I got for giving a series of lectures on the basic mathematical principles of drug-receptor interaction, a few years ago.” I spend a lot of my spare time, and a bit of my own money, in an attempt to bring some sense into the arguments. The alternative medicine gurus make their livings (in some cases large fortunes) out of their wares. So who has the vested interest? ### Does chiropractic actually cause stroke? As in the case of drugs and diet, it is remarkably difficult to be sure about causality. A patient suffers a vertebral artery dissection shortly after visiting a chiropractor, but did the neck manipulation cause the stroke? Or did it precipitate the stroke in somebody predisposed to one? Or is the timing just coincidence and the stroke would have happened anyway? There has been a lot of discussion about this and a forthcoming analysis will tackle the problem of causality head-on, My assessment at the moment, for what it’s worth, is that there are some pretty good reasons to suspect that neck manipulation can be dangerous, but it seems that serious damage is rare. In a sense, it really doesn’t matter much anyway, because it is now apparent that chiropractic is pretty well discredited without having to resort to arguments about rare (though serious) effects. There is real doubt about whether it is even any good for back pain (see Cochrane review), and good reason to think that the very common claims of chiropractors to be able to cure infant colic, asthma and so on are entirely, ahem, bogus. (See also Steven Novella, ebm-first, and innumerable other recent analyses.) Chiropractic is entirely discredited, whether or not it may occasionally kill people. ### Complaint sent to UCL I had an enquiry about this problem also from my old friend George Lewith. I told him what had happened. Soon after this, a complaint was sent to Tim Perry and Jason Clarke, UCL’s Director and Deputy Director of Academic Services. The letter came not from Lewith or Owen, but from Lionel Milgom. Milgrom is well known in the magic medicine community for writing papers about how homeopathy can be “explained” by quantum entanglement. Unfortunately for him, his papers have been read by some real physicists and they are no more than rather pretentious metaphors. See, for example, Danny Chrastina’s analysis, and shpalman, here. Not to mention Lewis, AP Gaylard and Orac.  Dear Mr Perry and Mr Clark, I would like to bring to your attention an editorial (below) that appeared in the most recent issue of the New Zealand Medical Journal. In it, one of your Emeritus Professors, David Colquhoun, is accused of a serious ethical breach, and I quote – “Is it acceptable to make up a reference to try and slip any unsupported statement into a “scientific” argument and thereby give it some degree of credibility?” Professor Colquhoun is well-known for writing extensively and publicly excoriating many forms of complementary and alternative medicine, particularly with regard to the alleged unscientific nature and unethical behaviour of its practitioners. Professor Colquhoun is also a voluble champion for keeping the libel laws out of science. While such activities are doubtlessly in accord with the venerable Benthamite liberal traditions of UCL, I am quite certain hypocrisy is not. And though Professor Colquhoun has owned up to his error, as the NZMJ’s editor implies, it leaves a question mark over his credibility. As custodians of the college’s academic quality therefore, you might care to consider the possible damage to UCL’s reputation of perceived professorial cant; emeritus or otherwise. Yours Sincerely Dr Lionel R Milgrom So, as we have seen, the quotation was correct, the reference was correct, and I’d read the article from which it came I made a mistake in citing the original paper rather than the web version of the same paper.. I leave it to the reader to judge whether this constitutes a "serious ethical breach", whether I’d slipped in an "unsupported statement", and whether it constitutes "hypocrisy" ### Follow-up It so happens that no sooner was this posted than there appeared Part 2 of the devastating refutation of Lionel Milgrom’s attempt to defend homeopathy, written by AP Gaylard. Thanks to Mojo (comment #2) for pointing this out. Jump to follow-up I’m perfectly happy to think of alternative medicine as being a voluntary, self-imposed tax on the gullible (to paraphrase Goldacre again). But only as long as its practitioners do no harm and only as long as they obey the law of the land. Only too often, though, they do neither. When I talk about law, I don’t mean lawsuits for defamation. Defamation suits are what homeopaths and chiropractors like to use to silence critics. heaven knows, I’ve becomes accustomed to being defamed by people who are, in my view. fraudsters, but lawsuits are not the way to deal with it. I’m talking about the Trading Standards laws Everyone has to obey them, and in May 2008 the law changed in a way that puts the whole health fraud industry in jeopardy. The gist of the matter is that it is now illegal to claim that a product will benefit your health if you can’t produce evidence to justify the claim. I’m not a lawyer, but with the help of two lawyers and a trading standards officer I’ve attempted a summary. The machinery for enforcing the law does not yet work well, but when it does, there should be some very interesting cases. The obvious targets are homeopaths who claim to cure malaria and AIDS, and traditional Chinese Medicine people who claim to cure cancer. But there are some less obvious targets for prosecution too. Here is a selection of possibilities to savour.. • Universities such as Westminster, Central Lancashire and the rest, which promote the spreading of false health claims • Hospitals, like the Royal London Homeopathic Hospital, that treat patients with mistletoe and marigold paste. Can they produce any real evidence that they work? • Edexcel, which sets examinations in alternative medicine (and charges for them) • Ofsted and the QCA which validate these exams • Skills for Health and a whole maze of other unelected and unaccountable quangos which offer “national occupational standards” in everything from distant healing to hot stone therapy, thereby giving official sanction to all manner of treatments for which no plausible evidence can be offered. • The Prince of Wales Foundation for Integrated Health, which notoriously offers health advice for which it cannot produce good evidence • Perhaps even the Department of Health itself, which notoriously referred to “psychic surgery” as a profession, and which has consistently refused to refer dubious therapies to NICE for assessment. The law, insofar as I’ve understood it, is probably such that only the first three or four of these have sufficient commercial elements for there to be any chance of a successful prosecution. That is something that will eventually have to be argued in court. But lecanardnoir points out in his comment below that The Prince of Wales is intending to sell herbal concoctions, so perhaps he could end up in court too. ### The laws We are talking about The Consumer Protection from Unfair Trading Regulations 2008. The regulations came into force on 26 May 2008. The full regulations can be seen here, or download pdf file. They can be seen also on the UK Statute Law Database. The Office of Fair Trading, and Department for Business, Enterprise & Regulatory Reform (BERR) published Guidance on the Consumer Protection from Unfair Trading Regulations 2008 (pdf file), Statement of consumer protection enforcement principles (pdf file), and The Consumer Protection from Unfair Trading Regulations: a basic guide for business (pdf file). Has The UK Quietly Outlawed “Alternative” Medicine? On 26 September 2008, Mondaq Business Briefing published this article by a Glasgow lawyer, Douglas McLachlan. (Oddly enough, this article was reproduced on the National Center for Homeopathy web site.) “Proponents of the myriad of forms of alternative medicine argue that it is in some way “outside science” or that “science doesn’t understand why it works”. Critical thinking scientists disagree. The best available scientific data shows that alternative medicine simply doesn’t work, they say: studies repeatedly show that the effect of some of these alternative medical therapies is indistinguishable from the well documented, but very strange “placebo effect” ” “Enter The Consumer Protection from Unfair Trading Regulations 2008(the “Regulations”). The Regulations came into force on 26 May 2008 to surprisingly little fanfare, despite the fact they represent the most extensive modernisation and simplification of the consumer protection framework for 20 years.” The Regulations prohibit unfair commercial practices between traders and consumers through five prohibitions:- • General Prohibition on Unfair Commercial Practices (Regulation 3) • Prohibition on Misleading Actions (Regulations 5) • Prohibition on Misleading Omissions (Regulation 6) • Prohibition on Aggressive Commercial Practices (Regulation 7) • Prohibition on 31 Specific Commercial Practices that are in all Circumstances Unfair (Schedule 1). One of the 31 commercial practices which are in all circumstances considered unfair is “falsely claiming that a product is able to cure illnesses, dysfunction or malformations”. The definition of “product” in the Regulations includes services, so it does appear that all forms medical products and treatments will be covered. Just look at that!  One of the 31 commercial practices which are in all circumstances considered unfair is “falsely claiming that a product is able to cure illnesses, dysfunction or malformations” Section 5 is equally powerful, and also does not contain the contentious word “cure” (see note below) Misleading actions 5.—(1) A commercial practice is a misleading action if it satisfies the conditions in either paragraph (2) or paragraph (3). (2) A commercial practice satisfies the conditions of this paragraph— (a) if it contains false information and is therefore untruthful in relation to any of the matters in paragraph (4) or if it or its overall presentation in any way deceives or is likely to deceive the average consumer in relation to any of the matters in that paragraph, even if the information is factually correct; and (b) it causes or is likely to cause the average consumer to take a transactional decision he would not have taken otherwise. These laws are very powerful in principle, But there are two complications in practice. One complication concerns the extent to which the onus has been moved on to the seller to prove the claims are true, rather than the accuser having to prove they are false. That is a lot more favourable to the accuser than before, but it’s complicated. The other complication concerns enforcement of the new laws, and at the moment that is bad. ### Who has to prove what? That is still not entirely clear. McLachlan says “If we accept that mainstream evidence based medicine is in some way accepted by mainstream science, and alternative medicine bears the “alternative” qualifier simply because it is not supported by mainstream science, then where does that leave a trader who seeks to refute any allegation that his claim is false? Of course it is always open to the trader to show that his the alternative therapy actually works, but the weight of scientific evidence is likely to be against him.” On the other hand, I’m advised by a Trading Standards Officer that “He doesn’t have to refute anything! The prosecution have to prove the claims are false”. This has been confirmed by another Trading Standards Officer who said “It is not clear (though it seems to be) what difference is implied between “cure” and “treat”, or what evidence is required to demonstrate that such a cure is false “beyond reasonable doubt” in court. The regulations do not provide that the maker of claims must show that the claims are true, or set a standard indicating how such a proof may be shown.” The main defence against prosecution seems to be the “Due diligence defence”, in paragraph 17. Due diligence defence 17. —(1) In any proceedings against a person for an offence under regulation 9, 10, 11 or 12 it is a defence for that person to prove— (a) that the commission of the offence was due to— (i) a mistake; (ii) reliance on information supplied to him by another person; (iii) the act or default of another person; (iv) an accident; or (v) another cause beyond his control; and (b) that he took all reasonable precautions and exercised all due diligence to avoid the commission of such an offence by himself or any person under his control. If “taking all reasonable precautions” includes being aware of the lack of any good evidence that what you are selling is effective, then this defence should not be much use for most quacks. Douglas McLachlan has clarified, below, this difficult question ### False claims for health benefits of foods A separate bit of legislation, European regulation on nutrition and health claims made on food, ref 1924/2006, in Article 6, seems clearer in specifying that the seller has to prove any claims they make. Article 6 Scientific substantiation for claims 1. Nutrition and health claims shall be based on and substantiated by generally accepted scientific evidence. 2. A food business operator making a nutrition or health claim shall justify the use of the claim. 3. The competent authorities of the Member States may request a food business operator or a person placing a product on the market to produce all relevant elements and data establishing compliance with this Regulation. That clearly places the onus on the seller to provide evidence for claims that are made, rather than the complainant having to ‘prove’ that the claims are false. On the problem of “health foods” the two bits of legislation seem to overlap. Both have been discussed in “Trading regulations and health foods“, an editorial in the BMJ by M. E. J. Lean (Professor of Human Nutrition in Glasgow). “It is already illegal under food labelling regulations (1996) to claim that food products can treat or prevent disease. However, huge numbers of such claims are still made, particularly for obesity ” “The new regulations provide good legislation to protect vulnerable consumers from misleading “health food” claims. They now need to be enforced proactively to help direct doctors and consumers towards safe, cost effective, and evidence based management of diseases.” In fact the European Food Standards Agency (EFSA) seems to be doing a rather good job at imposing the rules. This, predictably, provoked howls of anguish from the food industry There is a synopsis here. “Of eight assessed claims, EFSA’s Panel on Dietetic Products, Nutrition and Allergies (NDA) rejected seven for failing to demonstrate causality between consumption of specific nutrients or foods and intended health benefits. EFSA has subsequently issued opinions on about 30 claims with seven drawing positive opinions.” “. . . EFSA in disgust threw out 120 dossiers supposedly in support of nutrients seeking addition to the FSD’s positive list. If EFSA was bewildered by the lack of data in the dossiers, it needn’t hav been as industry freely admitted it had in many cases submitted such hollow documents to temporarily keep nutrients on-market.” Or, on another industry site, “EFSA’s harsh health claim regime “By setting an unworkably high standard for claims substantiation, EFSA is threatening R&D not to mention health claims that have long been officially approved in many jurisdictions.” Here, of course,”unworkably high standard” just means real genuine evidence. How dare they ask for that! ### Enforcement of the law 19. —(1) It shall be the duty of every enforcement authority to enforce these Regulations. (2) Where the enforcement authority is a local weights and measures authority the duty referred to in paragraph (1) shall apply to the enforcement of these Regulations within the authority’s area. Nevertheless, enforcement is undoubtedly a weak point at the moment. The UK is obliged to enforce these laws, but at the moment it is not doing so effectively. A letter in the BMJ from Rose & Garrow describes two complaints under the legislation in which it appears that a Trading Standards office failed to enforce the law. They comment ” . . . member states are obliged not only to enact it as national legislation but to enforce it. The evidence that the government has provided adequate resources for enforcement, in the form of staff and their proper training, is not convincing. The media, and especially the internet, are replete with false claims about health care, and sick people need protection. All EU citizens have the right to complain to the EU Commission if their government fails to provide that protection.” This is not a good start. A lawyer has pointed out to me “that it can sometimes be very difficult to get Trading Standards or the OFT to take an interest in something that they don’t fully understand. I think that if it doesn’t immediately leap out at them as being false (e.g “these pills cure all forms of cancer”) then it’s going to be extremely difficult. To be fair, neither Trading Standards nor the OFT were ever intended to be medical regulators and they have limited resources available to them. The new Regulations are a useful new weapon in the fight against quackery, but they are no substitute for proper regulation.” Trading Standards originated in Weights and Measures. It was their job to check that your pint of beer was really a pint. Now they are being expected to judge medical controversies. Either they will need more people and more training, or responsibility for enforcement of the law should be transferred to some more appropriate agency (though one hesitates to suggest the MHRA after their recent pathetic performance in this area). ### Who can be prosecuted? Any “trader”, a person or a company. There is no need to have actually bought anything, and no need to have suffered actual harm. In fact there is no need for there to be a complainant at all. Trading standards officers can act on their own. But there must be a commercial element. It’s unlikely that simply preaching nonsense would be sufficient to get you prosecuted, so the Prince of Wales is, sadly, probably safe. Universities who teach that “Amethysts emit high Yin energy” make an interesting case. They charge fees and in return they are “falsely claiming that a product is able to cure illnesses”. In my view they are behaving illegally, but we shan’t know until a university is taken to court. Watch this space. The fact remains that the UK is obliged to enforce the law and presumably it will do so eventually. When it does, alternative medicine will have to change very radically. If it were prevented from making false claims, there would be very little of it left apart from tea and sympathy ### Follow-up New Zealand must have similar laws. Just as I was about to post this I found that in New Zealand a “couple who sold homeopathic remedies claiming to cure bird flu, herpes and Sars (severe acute respiratory syndrome) have been convicted of breaching the Fair Trading Act.” They were ordered to pay fines and court costs totalling$23,400.

A clarification form Douglas McLachlan

On the difficult question of who must prove what, Douglas McLachlan, who wrote Has The UK Quietly Outlawed “Alternative” Medicine?, has kindly sent the following clarification.

“I would agree that it is still for the prosecution to prove that the trader committed the offence beyond a reasonable doubt, and that burden of proof is always on the prosecution at the outset, but I think if a trader makes a claim regarding his product and best scientific evidence available indicates that that claim is false, then it will be on the trader to substantiate the claim in order to defend himself. How will the trader do so? Perhaps the trader might call witness after witness in court to provide anecdotal evidence of their experiences, or “experts” that support their claim – in which case it will be for the prosecution to explain the scientific method to the Judge and to convince the Judge that its Study evidence is to be preferred.

Unfortunately, once human personalities get involved things could get clouded – I could imagine a small time seller of snake oil having serious difficulty, but a well funded homeopathy company engaging smart lawyers to quote flawed studies and lead anecdotal evidence to muddy the waters just enough for a Judge to give the trader the benefit of the doubt. That seems to be what happens in the wider public debate, so it’s easy to envisage it happening a courtroom.”

The “average consumer”.

(3) A commercial practice is unfair if—

(a) it contravenes the requirements of professional diligence; and

(b) it materially distorts or is likely to materially distort the economic behaviour of the average consumer with regard to the product.

It seems,therefore, that what matters is whether the “average consumer” would infer from what is said that a claim was being made to cure a disease. The legal view cited by Mojo (comment #2, below) is that expressions such as “can be used to treat” or “can help with” would be considered by the average consumer as implying successful treatment or cure.

The drugstore detox delusion. A nice analysis “detox” at .Science-based Pharmacy

Shortly after I published my editorial in the New Zealand Medical Journal, Dr Who?, I was delighted to get a letter from someone who had trained in chiropractic and seen it all from the inside.

Sadly this wonderful letter had to be removed within a few weeks of posting it because its author was threatened and bullied by chiropractors. Its author is too young and too vulnerable to risk his future career. As a result of this shameful and vindictive treatment, I was asked to remove the letter and did so immediately.  Other copies on the web have now vanished too.

The experiences described in the letter justified much of what I said in the editorial, and in some ways went further.  This letter doubtless contributed to dropping of the threatened legal action by chiropractors against the Journal and against me.  The letter was posted originally on 21 August 2008, with the permission of its author.  See also the follow-up in Chiropractic wars. Part 3: internecine conflict.

Now I have been sent a much more anonymous version, and it is a great pleasure to post this inside information.

All I can say is, don’t thank me. It doesn’t take much courage at my age.  It takes a lot at yours and the world should be grateful to you.

### Replies from chiropractors in the NZMJ

The New Zealand Medical Journal, very properly, allowed right of reply to chiropractore. This week’s issue contains three letters, one of which is from Paul Kelly. It is signed “Dr Brian Kelly B App Sci (Chiro), President, New Zealand College of Chiropractic”. This is not quite the same as appears on his College’s web site which shows the president’s welcome.

It seems that Kelly has not been quite so careful about use of his title on the web site because (as of 21 August) the signature on his address looks like this.

Dr Brian Kelly, President”. That does seem a bit careless, given that his usage of “Dr” was pointed out in my original editorial, published on 25th July.

Replies to these letters appeared in the September 5th issue of NZMJ.

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].

### 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.

An editorial in today’s issue of the New Zealand Medical Journal prints in full a letter sent to the Journal by Paul Radich, a lawyer who acts for the New Zealand Chiropractors’ Association Inc and its members. The letter alleges defamation by Andrew Gilbey’s article, and by my editorial which sets the wider context of his paper. The articles in question are here.

Here are some quotations from the Editorial by the Journal’s editor, Professor Frank A Frizelle, Department of Surgery, Christchurch Hospital, NZ. [Download the whole editorial].

 In the article by Gilbey, data is provided about use of inappropriate titles by New Zealand practitioners of acupuncture, chiropractic, and osteopathy while the greater context is provided by Colquhoun. The comments made by Paul Radich are entirely consistent with the response as expressed by Professor Edzard Ernst (Editor-in-Chief of Focus on Alternative and Complementary Medicine (FACT) and Chair in Complementary Medicine at the University of Exeter) in his humorous article In praise of the data-free discussion. Towards a new paradigm5 when he states “data can be frightfully intimidating and non-egalitarian”. . . . The Journal has a responsibility to deal with all issues and not to steer clear of those issues that are difficult or contentious or carry legal threats. Let the debate continue in the evidence-based tone set by Colquhoun and others. I encourage, as we have done previously, the chiropractors and others to join in, let’s hear your evidence not your legal muscle.

My article said nothing that has not been said many times before. I regard it as fair scientific comment, and I believe that expression of those opinions is in the public interest, The reaction of the Journal is thoroughly admirable.

The outcome of legal bullying can be very counterproductive, as the UK’s Society of Homeopaths found recently to their cost.

The lawyers’ letter demanded a response by 11th August, but in the advice of a lawyer I have decided to ignore for now this rather crude attempt to stifle discussion.

For further developments, watch this space.

The story was picked up within hours, It seems that a storm may be brewing round the world for New Zealand Chiropractors. Here are some of them.

HolfordWatch Professor Frizelle’s Instant Classic: Let’s hear your evidence not your legal muscle

The first New Zealand site.

More Legal Chill -from spine-cracking chiropractors on jdc325’s blog

And A beginners guide to chiropractic, on the same site.

Andy Lewis’s Quackometer takes a sharp look too, in They are bone doctors aren’t they?

Support from a NZ blog, Evidence-based thought NZ Chiropractors vs NZ Medical Journal

And another New Zealand blog, Chiropractors attack NZ Medical Journal on SillyBeliefs.com

and another: Evidence should trump “legal muscle”, on “Open Parachute. The mind doesn’t work if it’s closed”

New Zealand Doctor magazine. “Kiwi-practors legal wrangle” in the Nature world news blog, The Great Beyond.

“Self-destructing chiropractors” on Jonathan Hearsay’s blog is particularly interesting because he is a (sceptical) osteopath. He says “Chiropractors are seemingly hell-bent on destroying themselves as a therapy”.

There are now so many allusions on the web to the behaviour of the New Zealand Chiropractors’ Association Inc that I’ll give up trying to list all of them. Their action seems tp have done much to damage their own reputation.

Shortly after this came the news that the British Chiropractic Association is to sue one of out best science communicators, Simon Singh, because he had the temerity to inspect the evidence and give his opinion about it in the Guardian. His original article has gone (for now) from the Guardian web site, but as always happens with attempts at bullying and intimidation, it is more easily available then ever, For example here, and here.

Chiropractic in the UK is analysed by Andy Lewis on Quackometer,

The article below is an editorial that I was asked to write for the New Zealand Medical Journal, as a comment on article in today’s edition about the misuse of the title ‘doctor’ by chiropractors [download pdf]. Titles are not the only form of deception used by chiropractors, so the article looks at some of the others too.  For a good collection of articles that reveal chiropractic for what it is, look at Chirobase

THE NEW ZEALAND
MEDICAL JOURNAL

Journal of the New Zealand Medical Association

NZMJ 25 July 2008, Vol 121 No 1278; ISSN 1175 8716

Doctor Who?
Inappropriate use of titles by some alternative “medicine” practitioners

David Colquhoun

Who should use the title ‘doctor’? The title is widely abused as shown by Gilbey1 in this issue of the NZMJ in an article entitled Use of inappropriate titles by New Zealand practitioners of acupuncture, chiropractic, and osteopathy. Meanwhile, Evans and colleagues 2, also in this issue, discuss usage and attitudes to alternative treatments.

Gilbey finds that the abuse of the title doctor is widespread and that chiropractors are the main culprits. An amazing 82% of 146 chiropractics used the title Doctor, andL most of them used the title to imply falsely that they were registered medical practitioners.

Although it is illegal in New Zealand to do that, it seems clear that the law is not being enforced and it is widely flouted. This is perhaps not surprising given the history of chiropractic. It has had a strong element of ruthless salesmanship since it was started in Davenport, Iowa by D.D. Palmer (1845–1913). His son, B.J. Palmer, said that their chiropractic school was founded on “a business, not a professional basis. We manufacture chiropractors. We teach them the idea and then we show them how to sell” (Shapiro 2008)3 It is the same now. You can buy advice on how to build “build high-volume, subluxation-based, cash-driven, lifetime family wellness practices”

In her recent book3 , Rose Shapiro comments on the founder of chiropractic as follows.

“By the 1890s Palmer had established a magnetic healing practice in Davenport, Iowa, and was styling himself “doctor”. Not everyone was convinced, as a piece about him in an 1894 edition of the local paper, the Davenport Leader, shows.

A crank on magnetism has a crazy notion hat he can cure the sick and crippled with his magnetic hands. His victims are the weak-minded, ignorant and superstitious,those foolish people who have been sick for years and have become tired of the regular physician and want health by the short-cut method he has certainly profited by the ignorance of his victim. His increase in business shows what can be done in Davenport, even by a quack.”

D.D. Palmer was a curious mixture: grocer, spiritual healer, magnetic therapist, fairground huckster, religious cult leader—and above all, a salesman. He finally found a way to get rich by removing entirely imaginary “subluxations”.

Over 100 years later, it seems that the “weak-minded, ignorant, and superstitious” include the UK’s Department of Health, who have given chiropractics a similar status to the General Medical Council.

The intellectual standards of a 19th Century Mid-Western provincial newspaper journalist are rather better than the intellectual standards of the UK’s Department of Health, and of several university vice-chancellors in 2007.

### Do the treatments work?

Neither Gilbey nor Evans et al. really grasp the nettle of judging efficacy. The first thing one wants to know about any treatment —alternative or otherwise — is whether it works. Until that is decided, all talk of qualifications, regulation, and so on is just vacuous bureaucratese. No policy can be framed sensibly until the question of efficacy has been addressed honestly.

It is one good effect of the upsurge of interest in alternative treatments that there are now quite a lot of good trials of the most popular forms of treatments (as well as many more bad trials). Some good summaries of the results are now available too. Cochrane reviews set the standard for good assessment of evidence. New Zealand’s Ministry of Health commissioned the Complementary and Alternative Medicine
website to assess the evidence, and that seems to have done a good job too. Their assessment of chiropractic treatment of low back pain is as follows:

There appears to be some evidence from one systematic review and four other studies, although not conclusive, that chiropractic treatment is as effective as other therapies but this may be due to chance. There is very little evidence that chiropractic is more effective than other therapies.

And two excellent summaries have been published as books this year. Both are by people who have had direct experience of alternative treatments, but who have no financial interest in the outcome of their assessment of evidence. The book by Singh and Ernst4 summarises the evidence on all the major alternative treatments, and the book by Bausell5 concentrates particularly on acupuncture, because the author was for 5 years involved in research in that area, Both of these books come to much the same conclusion about chiropractic. It is now really very well-established that chiropractic is (at best) no more effective than conventional treatment. But it has the disadvantage of being surrounded by gobbledygook about “subluxations” and, more importantly, it kills the occasional patient.

Long (2004)7 said “the public should be informed that chiropractic manipulation is the number one reason for people suffering stroke under the age of 45.

The chiropractors of Alberta (Canada) and the Alberta Government are now facing a class-action lawsuit8. The lead plaintiff is Sandra Nette. Formerly she was a fit 41 year old. Now she is tetraplegic. Immediately
after neck manipulation by a chiropractor she had a massive stroke as a result of a torn vertebral artery.

Acupuncture comes out of the assessments equally badly. Bausell (2007) concludes that it is no more than a theatrical placebo.

### Are the qualifications even real?

It is a curious aspect of the alternative medicine industry that they often are keen to reject conventional science, yet they long for academic respectability. One aspect of this is claiming academic titles on the flimsiest of grounds. You can still be held to have misled the public into thinking you are a medical
practitioner, even if you have a real doctorate. But often pays to look into where the qualifications come from.

A celebrated case in the UK concerned the ‘lifestyle nutritionist’, TV celebrity and multi-millionaire, Dr Gillian McKeith, PhD. A reader of Ben Goldacre’s excellent blog, badscience.net did a little investigation. The results appeared in Goldacre’s Bad Science column in the Guardian9.

She claimed that her PhD came from the American College of Nutrition, but it turned out to come from a correspondence course from a non-accredited US ‘college’. McKeith also boasted of having “professional membership” of the American Association of Nutritional Consultants, for which she provided proof of her degree and three professional references.

The value of this qualification can be judged by the fact that Goldacre sent an application and \$60 and as a result “My dead cat Hettie is also a “certified professional member” of the AANC. I have the certificate hanging in my loo”.

### Is the solution government regulation?

In New Zealand the law about misleading the public into believing you are a medical practitioner already exists. The immediate problem would be solved if that law were taken seriously, but it seems that it is not.

It is common in both the UK and in New Zealand to suggest that some sort of official government regulation is the answer. That solution is proposed in this issue of NZMJ by Evans et al2. A similar thing has been proposed recently in the UK by a committee headed by Michael Pittilo, vice-chancellor of Robert Gordon’s University, Aberdeen.

I have written about the latter under the heading A very bad report. The Pittilo report recommends both government regulation and more degrees in alternative medicine. Given that we now know that most alternative medicine doesn’t work, the idea of giving degrees in such subjects must be quite ludicrous to any thinking person.

The magazine Nature7 recently investigated the 16 UK universities who run such degrees. In the UK, first-year students at the University of Westminster are taught that “amethysts emit high yin energy” . Their vice chancellor, Professor Geoffrey Petts, describes himself a s a geomorphologist, but he cannot be tempted to express an opinion about the curative power of amethysts.

There has been a tendency to a form of grade inflation in universities—higher degrees for less work gets bums on seats. For most of us, getting a doctorate involves at least 3 years of hard experimental research in a university. But in the USA and Canada you can get a ‘doctor of chiropractic’ degree and most chiropractic (mis)education is not even in a university but in separate colleges.

Florida State University famously turned down a large donation to start a chiropractic school because they saw, quite rightly, that to do so would damage their intellectual reputation. This map, now widely distributed on the Internet, was produced by one of their chemistry professors, and it did the trick.

Other universities have been less principled. The New Zealand College of Chiropractic [whose President styles himself “Dr Brian Kelly”,though his only qualification is B. App Sci (chiro)] is accredited by the New Zealand Qualifications Authority (NZQA). Presumably they, like their UK equivalent (the QAA), are not allowed to take into account whether what is being taught is nonsense or not. Nonsense courses are accredited by experts in nonsense. That is why much accreditation is not worth the paper it’s written on.

Of course the public needs some protection from dangerous or fraudulent practices, but that can be done better (and more cheaply) by simply enforcing existing legislation on unfair trade practices, and on false advertising. Recent changes in the law on unfair trading in the UK have made it easier to take legal action against people who make health claims that cannot be justified by evidence, and that seems the best
way to regulate medical charlatans.

### Conclusion

For most forms of alternative medicine—including chiropractic and acupuncture—the evidence is now in. There is now better reason than ever before to believe that they are mostly elaborate placebos and, at best, no better than conventional treatments. It is about time that universities and governments recognised the evidence and stopped talking about regulation and accreditation.

Indeed, “falsely claiming that a product is able to cure illnesses, dysfunction, or malformations” is illegal in Europe10.

Making unjustified health claims is a particularly cruel form of unfair trading practice. It calls for prosecutions, not accreditation.

Competing interests: None.
NZMJ 25 July 2008, Vol 121 No 1278; ISSN 1175 8716

Author information: David Colquhoun, Research Fellow, Dept of Pharmacology, University College London, United Kingdom (http://www.ucl.ac.uk/Pharmacology/dc.html)

Correspondence: Professor D Colquhoun, Dept of Pharmacology, University College London, Gower Street, London WC1E 6BT, United Kingdom. Fax: +44(0)20 76797298; email: d.colquhoun@ucl.ac.uk

References:

1. Gilbey A. Use of inappropriate titles by New Zealand practitioners of acupuncture, chiropractic, and osteopathy. N Z Med J. 2008;121(1278). [pdf]

2. Evans A, Duncan B, McHugh P, et al. Inpatients’ use, understanding, and attitudes towards traditional, complementary and alternative therapies at a provincial New Zealand hospital. N Z Med J. 2008;121(1278).

3 Shapiro. Rose. Suckers. How Alternative Medicine Makes Fools of Us All Random House, London 2008. (reviewed here)

4. Singh S, Ernst E. Trick or Treatment. Bantam Press; 2008 (reviewed here)

5. Bausell RB. Snake Oil Science. The Truth about Complementary and Alternative Medicine. (reviewed here)
Oxford University Press; 2007

6. Colquhoun D. Science degrees without the Science, Nature 2007;446:373–4. See also here.

7. Long PH. Stroke and spinal manipulation. J Quality Health Care. 2004;3:8–10.

8. Libin K. Chiropractors called to court. Canadian National Post; June21, 2008.

9. Goldacre B. A menace to science. London: Guardian; February 12, 2007/

10. Department for Business Enterprise & Regulatory Reform (BERR). Consumer Protection from Unfair Trading Regulations 2008. UK: Office of Fair Trading.