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BCA – DC's Improbable Science

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BCA

We all know that chiropractors feel pretty desperate, after their job has been revealed as baseless (much more information at ebm-first). Nonetheless it was very surprising when I was alerted by Twitter to the fact that the London Chiropractors were claiming to have been chosen by UCL as a "Centre of Excellence".

chiro2

That was the heading in the whole page devoted to crowing about this designation. The page, as it was on18th April, can be seen on freezepage.com. They even boast about our 21 Nobel prizewinners, as though they had endorsed chiropractic.

"London Chiropractor has recently been designated as a “Centre of Excellence” by University College London. The University is among the world’s leading universities as can be seen by its ranking in a variety of performance areas. Twenty-one Nobel prizewinners have come from the University’s community".

chiro-3s

The triumphalist crowing goes on

"The designation of London Chiropractor as a Centre of Excellence is something that we are sincerely proud of. It distinguishes our clinic while providing impetus to carry on with our multi-disciplinary and evidence based treatment strategies while looking for new ways in which to improve on all aspects of our clinic at the same time and in a continuous manner."

But chiropractic is undoubtedly in deep trouble, after more that 600 complaints were submitted to the General Chiropractic Council (GCC). The GCC was forced to renounce what has always been a central myth of chiropractic, the "subluxation". The fact that most of the complaints have been rejected has revealed huge deficiencies in the GCC (some of which it recently admitted). It also reveals the uselessness of the Council for Health Regulatory Excellence (CHRE).which is meant to supervise them. More details at quackometer, Chiropractors at War with their Regulator, the GCC.

In the words of Richard Brown (president of the BCA) himself,

"The BCA sued Simon Singh personally for libel. In doing so, the BCA began one of the darkest periods in its history; one that was ultimately to cost it financially,"

Needless to say, chiropractors are trying to cash in on the Olympic games, sadly, with a little success. I suppose that invoking UCL. was part of that attempt. Like so many of chiropractors’ attempts to defend themselves, it misfired badly.

The inspection of evidence that followed the attempt by the British Chiropractic Association (BCA) to sue Simon Singh showed that he was entirely justified to describe many of their treatments as “bogus” and “without a jot of evidence”.

A quick email to the UCL authorities quickly determined that the claimed endorsement was not true. Attempting to access this page now leads to “page not found". The page vanished on Sunday 22nd April, and a near identical page for the Broadgate Spine and Joint Clinic had already vanished on Friday 20th April. While it is true that two surgeons from UCL’s Institute of Sports Medicine have worked in the same building, they neither use chiropractic nor endorse it.

I’m assured that the alleged endorsement never happened. London Chiropractors won’t say where it came from. It seems that it was simply made up. I think that’s called a lie. I presume it is a sign of the desperation of chiropractors.

Follow-up

Jump to follow-up

Peter Dixon is a chiropractor. He is chair of the General Chiropractic Council (GCC). He was also a member of the hotly-disputed NICE low back pain guidance group that endorsed (you guessed it) the use of chiropractic, a decision that has led to enormous criticism of the standards of the National Institute of health and Clinical Excellence (NICE).

As a consequence largely of the decision of the British Chiropractic Association (BCA) to sue Simon Singh for defamation, there has been an unprecedented interest taken in the claims made by chiropractors in general.

Peter Dixon has a problem because something like 600 individual complaints about unjustified health claims have been sent to the GCC. Even when a web site does not claim to be able to benefit things like asthma and colic, a phone call may reveal that claims are made in private (one of the many complaints to the GCC concerns such behaviour by two practices belonging to, ahem, Peter Dixon Associates).

The crucial question is, as always, one of evidence. The BCA claim to have a plethora of evidence for their claims, but they have been strangely reluctant to produce it. In fact evidence is cited on the “Your first visit” page on Dixon’s site.

first visit

At the bottom we see “How effective is Chiropractic?”.

Meade paper

That sounds very impressive indeed: . ” . . . patients who received chiropractic treatment improved by 70% more than those given hospital out-patient.”

But hang on. If we look at the paper, Meade et al., 1990 [download reprint], we see that Figure 2 looks like this.

Meade 1990 Fig 2

Several things jump out. First, the Oswestry disability index scale runs for 0 to 100, but scores are plotted only from 0 to 35, so the size of the effects are exaggerated. Second, there are no error bars on the points. Third there is essentially no advantage for chiropractic at all when all patients are taken together (top graph). Fourth, and most important, the patients who were followed up for two years (bottom graph) seem to show a slight advantage for chiropractic but on average, the effect is 7 percent (on the 100 point scale, NOT 70 percent as claimed on the web site of Peter Dixon Associates.

What sort of mistake was made?

The abstract of the paper itself says “A benefit of about 7% points on the Oswestry scale was seen at two years.” How did this become “improved by 70% more”?

It could have been simple a typographical error, but that seems unlikely, Who’d boast about a 7% improvement?

Perhaps it is a question of relative versus absolute change. The Figure does not show the actual scores on the 100 point scale, but rather the change in score, relative to a questionnaire given just before starting treatment. If we look at the lower part of the Figure, restricted to those patients who stayed with the trail for 2 years (by this time 28% of the patients had dropped out), we see that there is a reduction in score (improvement) of about 10 points on the 100 point scale with hospital treatment (not a very impressive response). The improvement with those sent to private chiropractic clinics was about seven points bigger. So a change from 10 to 17 is a 70 percent change. What’s wrong with that?

What’s wrong is that it is highly misleading, as relative changes often are. Imagine that the hospital number had been 7 points and the chiropractic number had been 14 (both out of 100). That would mean that both treatments had provided very modest benefits to the patients. Would it then be fair to describe the chiropractic patients as have improved by 100 percent more than the hospital patients, when in fact neither got much benefit? Of course it would not. To present the results in this way would be highly deceptive.

Put another way, a 70% increase in a trivial effect is still pretty trivial.

That isn’t all either. The paper has been analysed in some detail on the ebm-first site. The seven point difference on a 100 point scale, though it may be real, is too small to be ‘clinically significant’ In other words the patient would scarcely notice such a small change. Another problem lies in the nature of the comparison. Patients were, quite properly, allocated at random to chiropractic or to to hospital treatment. BUT the comparion was very from blind. one group was treated in hospital. The other group was sent to private chiropractic clinics. The trivial 7 point difference could easily be as much to do with the thickness of the carpets rather than any effect of spinal manipulation.

What this paper really tells you is that neither treatment is very effective and that there is little to choose between them.

It is really most unfortunate that the chairman of the GCC should show himself to be so careless about evidence at a time when the evidence for the claims of chiropractors is under inspection as never before. It does not add to their case for criticising Simon Singh and it does not add to one’s confidence in the judgement of the NICE guidance group.

free debate

Follow-up

The Pain Society revolt. A letter has been sent from several distinguished members of the British Pain Society to its President and Council.

“We, the undersigned, call upon the President of the British Pain Society to issue a statement to NICE and to the press condemning outright the conclusions of the recent UK National Institute for Health and Clinical Excellence (NICE) guidelines . . .”

The sigificance of this letter is that the present president of the British Pain Society is Professor Paul Watson who was a member of the NICE guidance group that produced the recommendations which have engendered such criticism. He was clinical advisor to the guidance group. There is a video of Paul Watson talking about back pain, that seems to me to illustrate very well the problem with the guidance. He says it is a huge problem (everyone knows that) and that something must be done, but he doesn’t say what. There is no admission that, in very many cases, nobody knows what to do. It is exactly this sort of hubris that that makes the NICE report so bad,

One caustic comment on the letter says

“We are led by a physiotherapist! A Professor who cannot even interpret straight forward evidence when it is presented to him on a plate.
Who’s going to be the next BPS President? A Hospital Porter?”

Jump to follow-up

This is another short interruption in the epic self-destruction of chiropractors.  In a sense it is more serious.  One expects quacks to advocate quackery.  What you don’t expect is that the National Institute of Clinical Excellence (NICE) will endorse it.  Neither do you expect the Medicines and Healthcare products Regulatory Agency (MHRA) to betray its mandate to make sure that medicines work.

The saga of the NICE low back pain guidance has been the subject of a deluge of criticism, It seems doubtful that the guidance can survive, not least because of its absurd endorsement of chiropractic, at a time when chiropractic is undergoing self-immolation as a consequence of the persecution of Simon Singh by the British Chiropractic Association (see here, and here, and here, and here and thousands of other sites).

The other betrayal has come to the for after the MHRA approved highly misleading labelling of a homeopathic preparation.  At the time,
in 2006
, when the principle was approved by the MHRA, just about every scientific organisation, even the Royal Society, condemned the action.  What was discouraging that the clinical organisations all stayed silent.  It is still a mystery why the MHRA made this enormous mistake,  Some said that European regulations required it, but that is quite untrue, as Les Rose has shown.  It appears to have been the result of a pusillanimous MHRA bowing to pressure from a deeply unscientific Department of Health (a letter from Caroline Flint at the time borders on the surreal).

On 20 May 2009, the British Medical Journal printed an article Drugs agency grants its first licence to homoeopathic product by Deborah Cohen (available free). The comments were mostly highly critical of the MHRA. The BMJ asked, as it does from time to time, for my comment to be converted to a letter
for the print edition
. That isn’t freely available, so here it is.

Published 9 June 2009, doi:10.1136/bmj.b2333
Cite this as: BMJ 2009;338:b2333

Letters

Homoeopathic product licence

MHRA label seems to be illegal

The strap line for the Medicines and Healthcare products Regulatory Agency (MHRA) is “We enhance and safeguard the health of the public by ensuring that medicines and medical devices work and are acceptably safe.”

Yet the MHRA has made mockery of its own aims by ignoring the bit about “ensuring that medicines work” and allowing Arnica 30C pills to be labelled: “a homoeopathic medicinal product used within the homoeopathic tradition for the symptomatic relief of sprains, muscular aches, and bruising or swelling after contusions.”1

This label should be illegal anyway because the pills contain no trace of the ingredient on the label, but this deceit has been allowed through a legal loophole for a long time now. If you sold strawberry jam that contained not a trace of strawberry you’d be in trouble.

But I can see no legal loophole that allows the manufacturers of Arnica 30C to evade the provisions of the Consumer Protection from Unfair Trading Regulations 2008. 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 consumer protection laws apply to the way that “the average consumer” will interpret the label. The average consumer is unlikely to know that “used within the homoeopathic tradition” is a form of weasel words that actually means “there isn’t a jot of evidence that the medicine works.”

Since there is not the slightest evidence that Arnica 30C pills provide symptomatic relief of sprains, etc, the labelling that the MHRA has approved seems to be illegal. The MHRA is not selling anything itself, so I presume that it won’t find itself in court, but anyone who follows its advice could well do so.

Cite this as: BMJ 2009;338:b2333

David Colquhoun, research professor1

University College London, London WC1E 6BT


Competing interests: None declared.

References

  1. Cohen D. Drugs agency grants its first licence to homoeopathic product. BMJ 2009;338:b2055. (20 May.)

    [Free Full Text]

It is, I suppose, just a sign of the chaos that reigns in the multiple agencies and quangos responsible for ‘regulation’  that one arm of government proposes action that a different branch would consider illegal.  That is an inevitable consequence of trying to regulate something without first deciding whether it is nonsense or not.  The Department of Health appears to be quite incapable of grasping this simple and obvious fact.

Follow-up

Health: best treatments. The Guardian seems to the be picking up BMJ stories and ran this one.

The battle for freedom of speech is under way.

Simon Singh is a great science writer and communicator. He is author of The Big Bang, The Code Book, Fermat’s Last Theorem, and, with Edzard Ernst, Trick or Treatment. They are superb books (buy from Amazon). Simon Singh

When Singh had the temerity to express an honest opinion, based on the evidence, about that very curious branch of alternative medicine known as chiropractic, the British Chiropractic Association sued Singh for defamation.This was their substitute for producing evidence for their bizarre claims.

Chiropractors seem to be particularly fond of litigation, perhaps because they are so short of evidence. Having had legal threats from them myself, I know how scary it can be, Luckily I was saved by a feisty a journal editor.  Singh wasn’t so lucky.  The history is recounted here,

The legal aspects of the case are being described by the lawyer who writes under the name of Jack of Kent. He has regular updates on progress.

Put briefly, Libel: A very expensive remedy, to be used only when you have no evidence. Appeals to alternative practitioners because truth is irrelevant

The iniquitous nature of England’s libel law has been described eloquently by Nick Cohen, in the Observer. It is used regularly by rogues and criminals from all over the world to silence their critics. All they need is money. Truth is irrelevant. It is a disgrace to a civilised country.

The cost of defamation cases in the UK is vastly greater than in any other country in Europe:: look at the graph.

With enormous courage, Simon Singh has decided to appeal against the ruling by Mr Justice Eady. Scientists and journalists everywhere should rally to support him, if they value the right to express an honest opinion without being bankrupted by a law court. Singh is taking a great risk on behalf of anyone who values freedom of speech.

free debate

The charity, Sense abour Science (SaS), has started a campaign to Keep the Libel Laws out of Science.

Read the statement about the campaign on the SaS site, and the current list of signatories. The list of supporters is already very impressive. It includes, for example, professor Lord (Martin) Rees, president of the Royal Society and Astronomer Royal, to Dr Philip Campbell Editor-in-Chief of Nature, David Starkey Historian, Stephen Fry Broadcaster and Author and Baroness Helena Kennedy QC Barrister.

You can sign the statement yourself there. Do it. Now!

You can also get code for the button (above) to link your own web site to the campaign.

In 1894, a local Iowa newspaper, The Davenport Leader, wrote of the founder of chripractic, D.D. Palmer, thus.

“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.” [quoted in Rose
Shapiro’s book, Suckers
]

Today, in the UK, no newspaper would dare to express an opinion like that.

We all hope that Singh will win the appeal.  But even if he doesn’t win in the law courts, he will have scored an enormous moral victory.  What’s more, chiropractic is now under scrutiny as never before.  There is going to be a chiro-fest that will make the British Chiropractic Association rue the day that it decided to use legal bullying in place of reason.

They may even have signed their own death warrant.

Follow up will be posted here regularly

Follow-up

There is a good roundup of activity up to June 3rd here.

The Wall Street Journal (June 4th) discusses the case under the title Britain Chills Free Speech.

British Medical Journal editorial by Evan Harris (Lib dem member of parliament and doctor), Science in Court

Bait and switch. Oh dear, oh dear. Just look at British Chiropractic Association tell their members to hide their sins from prying eyes.

Excellent round-up of the recent outburst of writing about “chiroquacktic” (Tut, tut, is there no respect?).

Dr Crippen writes “NICE recommends a cure for all known disease” [Ed some exaggeration, surely]