Skeptical Dad: Alternative medicine in parenting

By Matt Kaiser

Part I: what’s so wrong with it in pregnancy?

As someone of a sceptical persuasion, I have never really considered taking complementary or alternative medicine (CAM). I prefer my medicine evidence based.

During my first year as a dad, however, I have noticed that CAM seems particularly rife in pregnancy and childbirth. My anecdotal impression seems to be backed up by further analysis - a systematic review of scientific studies reported that more women than men use CAM in general and many continue to use CAM therapies throughout their pregnancy. Various analyses have estimated that, in the UK, at least 10% of people use some form of CAM within a given year, with other countries reporting a far higher usage. This supports a multi-billion pound global business, with the potential for a significant health impact on the population.

Conception

It started, for me at least, before my partner got pregnant. As is common, we didn’t conceive straightaway and so we started reading about how to maximise our chances. Many ‘natural health’ practitioners offer services for want-to-be mothers, such as reflexology, reiki ("prepare the body for birth"), acupuncture ("treatment of Kidney Yin and Yang"), dietary advice ("choose foods with strong life force!"), detox ('fertility cleansing'), massage ("help the body to become balanced") and homeopathy ("recondition the uterus, fallopian tubes and ovaries"). There are also treatments for male fertility, which promise to "stimulate the body’s own ability to heal itself" with homeopathy or by strengthening Kidney Jing with acupuncture (for at least three months, of course!).

[caption id=”” align=”alignleft” width=”217”] XKCD: Dilution[/caption]

This is despite no robust evidence to show that these treatments themselves actually boost fertility or increase conception rates. Reflexology or reiki does not provide ‘energy healing’, acupuncture has no effect on oviduct blockages or uterus blood nourishment, homeopathy does not change the cervical mucus or restore ‘sexual energy’, and massages cannot affect hormonal balance or the position of the uterus (all genuine claims). CAM practitioners’ websites invariably either quote testimonials, provide no research citations (even despite frequently stating that “research shows…”) or link to single, small-scale studies of dubious quality. More conclusive analyses, however, are severely lacking.

There is strong evidence of what does work to raise the likelihood of a woman conceiving: having frequent sex and timing intercourse at particular periods of the menstrual cycle, reducing or stopping smoking and losing weight, avoiding certain ‘teratogenic’ medications and agents, and conceiving at a younger age. It is also worth remembering that, on average, the probability of a women becoming pregnant within one menstrual cycle is around 20%, but that subfertility requiring specialist intervention affects only 10-15% of individuals. In effect, all that’s needed is time. In light of this, any testimonial claiming causality for a complementary fertility technique stands on pretty shaky ground.

What is even more disturbing, at least to me, is the promotion of various quack therapies to aid successful in-vitro fertilisation (IVF). These include distant spiritual healing to ‘nourish aura, chakras and meridians’, as well as opening relevant acupuncture channels to supply ‘more energy to the uterus and enhance receptivity’. Again, proper scientific scrutiny suggests these approaches do not work any better than placebo controls.

Assisted conception is a potentially anxious and distressing time, not to mention a potentially expensive one, and to my mind the last thing a couple needs is to invest faith and money in ‘therapies’ that don’t work.

Pregnancy

But the ‘alternative’ care had only just started. Once the little blue cross appeared on the white stick, there was a host of holistic approaches to supposedly see through a stress-free and uncomplicated pregnancy. Many boast of their ability to help prevent miscarriage, such as with acupuncture, enzyme therapy, herbs, reiki and reflexology.

There are also promotions for certain clayey soil (“Nzu”) and some of the usual CAM suspects to ease morning sickness, Bach flower remedy to reduce anxiety ("acts directly on the emotions"!), homeopathy for haemorrhoids and indigestion, and chiropractic and moxibustion to reverse breech presentation.

As has been shown time and time again, many observed benefits of CAM are derived from a placebo effect: that is the improvement seen in a patient who believes that they’re taking an effective therapy, even if they’re actually taking a sham control. But, who cares if it’s a benign treatment if the whole experience leads to an improvement in wellbeing?

There’s some mileage in this argument when one considers that we know that a maternal stress during pregnancy can lead to adverse outcomes, such as low birthweight, prematurity and poor growth of the baby. And certain relaxation techniques may be effective at reducing anxiety. It categorically does not, however, mean that the many CAM practitioners should be able to make entirely false and unsubstantiated claims in advertising their products and services, as this sells something at a handsome price that should be part of standard care. It also legitimises CAM practitioners’ baseless declarations, so that patients may divert care from conventional medicine to CAM. This risks shunning effective treatment, which will also include an equivalent placebo boost, in favour of sham therapies that, at best, give rise to placebo only.

And that’s still assuming CAM is benign, which may not always be the case given some adverse effects reported.

Again, there is plenty of evidence-based advice on how to reduce risks of complications in pregnancy, such as stopping smoking to reduce the risk of low birth weight, avoiding alcohol to prevent foetal alcohol syndrome, folic acid supplementation to lower occurrences of neural tube defects (also for preconception), addressing any nutritional deficiencies, and the proper treatment/management of a range of diseases known to adversely effect development.

Childbirth

One of the more varied stream of recommendations we received was how to induce labour. The list included raspberry leaf tea, cumin tea, spicy curry, sex (and other sexual practices!), nipple stimulation, a long walk, cream cakes, a glass of wine, castor oil, pineapple, scrubbing the floor, driving over speed bumps, flying and parsley (see the Mumsnet thread for some stunning cases of coincidental correlations: "X worked for me. I took it when I was due and I went into labour the next day!"). And we also have our familiar friends: herbs, acupuncture (again!) and homeopathy (although I’m not sure how pulsatilla, a herbaceous plant, relates to labour in a “law of similars” way).

Whilst the push for all things ‘natural’ is seen at all stages, never does it appear so forcefully advocated than when it comes to labour. I’ve heard quotes such as, "labour is the most natural thing a women can do", "a women’s body is designed for childbirth" and "a women knows what to do in labour without drugs or machines".

There is a sizeable demand for 'natural' approaches to pain relief during labour and there is a variety of treatments touted. These include electrical stimulation across the skin (‘TENS’), aromatherapy, audio-analgesia and acupuncture, mind-body interventions (e.g. yoga & hypnosis), homeopathy, traditional Chinese medicine, reflexology, and herbal medicines.

Unfortunately, there is insufficient evidence to make any call that these work or are more effective than placebo control (e.g. 1, 2, 3, 4 & 5). The Cochrane Pregnancy and Childbirth Group is undertaking a review into the efficacy of hypnosis for labour pain management, so the jury’s out on that one. Massage and relaxation techniques may help with pain and reduce the likelihood of obstetric intervention (but, guess what? More research needed!).

Arnica, a herbaceous plant often homeopathically prepared, was enthusiastically recommended for our hospital bag, supposedly to prevent bruising and promote healing. Except it doesn’t (1, 2 & 3).

It is, on the whole, likely to bedifficult to carry out interventionist, randomised studies on pregnant women. Who’d write that in their birth plan? So the data that do exist tend to be self-selected, unblinded, observational, often self-reported and prone to a myriad of confounding variables. But I guess that wouldn’t stop a CAM practitioner from cherry-picking a sweet biased result or two.

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I’m sure there are many more examples of alt med infiltrating pregnancy and childbirth, but I hope I’ve given a flavour of how widespread and enduring it is. My next post will be on the influence of mainstream healthcare professionals.

Burzynski: A media scandal

By Josephine Jones

An increasingly unwieldy list of well known serious legal and ethical issues has done nothing to stop the British media reporting on Dr Stanislaw Burzynski in an irresponsibly biased way. Such articles usually appear in the local press, though have also featured on ITV Daybreak, in the Daily Mirror and The Observer. They are always emotive, always full of hope and are presented from the point of view of families wishing to raise funds for ‘life saving‘ or ‘miracle‘ treatment. In doing so  – though of course they don’t see it this way, the media are effectively promoting the Burzynski Clinic.

When concerns are pointed out, heads are stuck deeper into the sand. Editors insist they are simply supporting a desperate family at a difficult time. They may even convince themselves that in mentioning that the treatment is ‘experimental’ or unproven, they are adequately reporting criticism of the clinic.

Critics are often accused of being heartless and sanctimonious. I don’t just refer to unnamed Twitter users, but also to people like the deputy editor and readers’ editor of The Observer, whose exaggerated reporting on critical bloggers left me feeling angry and personally insulted.

The latest newspaper to adopt this cowardly approach is the Reading Post, who have run a series of articles in support of a local family’s fundraising campaign. When I suggested to them that this kind of reporting is irresponsible, biased and misleads readers, I was told:

@_JosephineJones Our readers, and the family, are well aware of the surrounding issues. Faced with awful situation what else can you do?

The family may well be aware of the surrounding issues. I hope they are and that they have come to a properly informed decision. However, the vast majority of Reading Post readers will be totally unaware of the depth of the problem – or indeed the sheer number of problems. I can say this confidently as I know full well that the Reading Post have not reported them. They told me:

@_JosephineJones We have done more than one story. See:http://bit.ly/Jd0JSn especially comments from dad, below.

I assume that was the most balanced article they could find. It is entitled “Amelia’s appeal for a miracle cure”. It describes the treatment as ‘experimental’ and states that antineoplaston therapy aims to “target the cancer without destroying normal cells”. I believe this misleadingly implies that the treatment is new and pioneering and that side-effects are minimal or non-existent. If I didn’t already know such a complaint would be a complete waste of time, I may even consider writing to the PCC. Although later comments (including one from Amelia’s father) address at least some of my concerns, I think it unlikely that the vast majority of the Reading Post’s readership will have seen them.

In challenging the Reading Post on Twitter, I was – predictably – shouted down immediately by @BurzynskiSaves, an anonymous and prolific tweeter and keen follower of the #Burzynski hashtag. Although this person claims not to be employed by the clinic, s/he discusses conversations with current patients:

@_JosephineJones I will share this w you 4 what its worth. I’ve been on the phone w pts who’ve sobbed over ur actions. U know not what u do

@_JosephineJones not according to the cancer patients & their families. I swear if u heard their voices over this u would delete everything.

In fact I have sobbed over my actions myself. Patients and their families have my full sympathy and I’m in no position to criticise their decision to go to the clinic. To be accused of attacking patients gets on my nerves and to upset them breaks my heart. But I’m not the villain here.

Patients and families who decide to use the media to raise money for their cause are putting themselves in the public eye. Newspapers may wish to support such causes, but they also have a duty not to mislead their readership.

Kind-hearted members of the public wishing to support these desperate families ought to know where their money is going. Cancer patients watching well meant but biased media coverage could be persuaded to look into having treatment at the clinic themselves. This is how the media are promoting Burzynski.

I hope that such patients are not under any illusions about what their realistic chances of recovery actually are and that they are made fully aware of the side effects associated with the treatment. I suspect that this is not the case.

Jennifer Keane discusses patient choice and informed consent here, where she concludes that

Patients deserve information, not infomercials.

If you’ve not read the whole post already, I recommend that you do so. It strikes me that those standing up for the clinic (whether they be patients, their families, anonymous Twitter users or journalists) are either not willing or not able to objectively assess dry facts or to recognise what is reliable evidence and what is not. As convincing as they may be, patient testimonials are emphatically not reliable evidence.

Dr Burzynski has been using antineoplastons for over three decades and has still not published any real evidence the treatment is either effective or safe. He has not had a single paper published in a respectable peer reviewed journal. Patient testimonials are all that supporters of the clinic have got. And they continue to use them even after the patients have died.

But some testimonials are less welcome. Wayne and Lisa Merritt set up a blog to share their experience of the clinic and received threatening emails from the infamous pseudo-lawyer Marc Stephens as a result.

Others have gone to the press. Following the death of her husband, Edward,Michele Price spoke to the Houston Chronicle. She said that Dr Burzynski had given them false hope that the treatment was working. He insisted that MRI scans showed the medication was working, even after other doctors had broken the news that Edward’s condition was terminal. The fact that the couple first contacted the clinic after watching a glowing report on CBS television’s ’48 Hours’ is a clear example of how the media promote the clinic.

Others have gone to the courts. I mentioned this to @BurzynskiSaves as part of the Twitter exchange mentioned above. I was invited to

@_JosephineJones show me more than one patient suing Dr #Burzynski

In fact there have been several instances where patients or their bereaved families have taken Dr Burzynski and his companies to court.

The most obvious example is Lola Quinlan, whose case has been fairly well documented. She told a local news source

I’d like to see them shut down.  That’s my hope, that he can’t do this to anybody else

She said she was drawn to the clinic by a video advertisement on their website, and she was hoping the so-called ‘magic bullet’ touted by the clinic would improve her condition.

It was so perfect that I couldn’t even believe it because they weren’t going to do the chemo, they weren’t going to do the radiation, they weren’t going to take anything out

Lola Quinlan is not alone. There is another lady – Robin Reid, a stage IV breast cancer patient, named in court documents alongside Ms Quinlan. According to their First Amended Petition (a public document which may be viewed on the Harris County District Clerk website), Ms Reid was induced by Burzynski’s promises and assurances to undergo radical cancer treatment services in lieu of traditional treatment. She alleges that the treatments were not FDA approved (as Dr Burzynski and his clinic had claimed). She says that the treatments did not work (as they had promised). She did not receive all the treatments she had paid for, nor was she refunded. The phenylbutyrate treatment also caused a huge strain on her liver. An oncologist from outside the Burzynski Clinic later told her she should never have taken phenylbutyrate tablets because of the risk to the liver. Furthermore, representatives of the clinic failed to return numerous calls during a time when she was experiencing excruciating pain.

There are more. For example, Dr Burzynski made a $300,000 settlement with Stanley and Bernice Zabodyn – a couple whose daughter, Kay Wimberley, died of cancer following unsuccessful treatment at his clinic. They believe that the treatment increased her pain and hastened her death.

In addition to these, the current Texas Medical Board case also contains details of two further patients who were alleged to have been treated negligently (Patients A & B) . The case does not make pleasant reading and could even result in the revocation of Dr Burzynski’s licence to practise. Details include failing to discuss details and side effects of the cocktail of apparently randomly prescribed drugs, failing to encourage a patient to complete a course of radiotherapy, failing to discuss the lack of efficacy of treatment (as had been demonstrated by MRI scans) and failing to discuss alternative treatment.

To those accusing me of not caring about patients: I do this because I care. As I’m sure did Michele Price, who recounted the final months of her husbands life, frequently breaking down in tears. She told the Houston Chronicle

Maybe I’ll deter someone else from making a bad decision. And it was a bad decision.

These stories have not been reported by the British media. If their reason for regurgitating the dubious words of Dr Burzynski and his supporters is that they care about patients then where are the articles about Lola Quinlan? When will we read about Robin Reid? Why has there been no mention of Wayne Merritt, Edward Price or Kay Wimberley? What about Patients A and B?

Lazy and cowardly journalism do real harm. It’s time some heads were pulled out of the sand.

The problem with homeopathy for babies

By Matt Kaiser

I never thought I’d end up writing about homeopathy for babies, but some things just take you by surprise.

For those that are unaware, a homeopathic preparation starts by taking a substance, usually one that would cause an ailment, and dilute it down to such a degree that none of the original substance remains. The belief is that water retains a ‘memory’ of the agent, which can then be used to treat the ailment. The more diluted the preparation, the more effective the supposed remedy is. To give an idea of the level of dilution of most standard homeopathic preparations, the Merseyside Skeptics made ‘homeopathic vodka’ and tested it on a few willing volunteers.

The arguments against homeopathy have been made effectively elsewhere, so I won’t re-tread those well-articulated paths too heavily, but will sum it up briefly. To support homeopathy, proponents usually 'cherry-pick' flimsy, uncorroborated evidence to try and prove efficacy, suggest that a placebo effect is still a positive effect (and so what’s the problem?), or simply argue that everyone has an unhindered choice to decide what treatments they use. The primary problem for me (for it’s a problem among many) is that patients replace or delay conventional treatment in favour of alternative treatment, often at a serious detriment to their health. This is exacerbated by the decision to make homeopathic treatments available on the NHS - justified by the Government with the patient choice argument - and by major pharmacies that lends legitimacy to the practice in many people’s minds. The Science and Technology Committee, however, conclude unequivocally that it’s not valid.

So what’s this got to do with babies?

Well, we’re fairly sure that my little boy’s teething at the moment. This can be a pretty painful process and we would, of course, like to reduce his discomfort as much as possible. So it was with this in mind that my wife bought some teething granules, on the recommendation of some her friends who swore by this particular brand.

Now imagine my surprise when I whipped out the box, in anticipation of riding to my son’s rescue and alleviate his pain, only to discover that these were homeopathic teething granules. First, the surprise that these even exist; and second, the puzzlement that my wife, knowing my somewhat sceptical nature towards ‘alternative’ medicine, had actually bought them for our son. On the second point, she assured me that she didn’t realise they were homeopathic - this fact is revealed only on the back of the packet - and that she was going only on the testimonials of her friends (common ‘evidence’ homeopaths produce). So I’ll give her the benefit of the doubt on that score.

But the first point, that homeopathic pain relief exists for babies, has been troubling me since. The preparation is a 6C dilution of ‘Chamomilla’ (or chamomile). This means that it has been diluted 10-12, or to 0.000000000001 of the original substance. In the ‘homeopathic vodka’ preparation, this would have been reached by the 6th cup of water. So a pretty extreme dilution. Leaving aside the homeopathic tenet that the diluted agent should cause the symptoms of the ailment ('like with like' theory) and, as far as I know, chamomile doesn’t cause teething-like pain, there’s scant evidence I could find of this substance’s pain relief qualities (as advertised) nor of its often assumed general calming properties (also this). Nevertheless, at a 10-12 dilution, it seems extraordinary that there would be enough active molecules to have any effect, and we know that water cannot retain a ‘memory’ of a solute.

As soon I saw that this was a homeopathic treatment, I convinced my wife that we needed to buy a proper teething pain relief. We bought some teething gel, with some well-tested analgesic and antiseptic compounds in it to treat the gums directly, as well as some general pain relieving medicines. And this, to me, demonstrates the crux of the issue: if we’d persisted with the homeopathic treatment, then we would have delayed using the more reliable teething gel and could have caused our son a few nights of needlessly heightened pain.

My wife, bearing in mind the gushing anecdotes about the efficacy of this treatment, suggested we could use them alongside the proven analgesics, thereby nullifying my argument about delaying proper treatment. There’s no harm in it and if the homeopathic granules did work, then that’d be a bonus! After all, our first priority is to provide some respite for our child.

But this still made me uncomfortable for a number of reasons. First, as a subscriber to evidence-based decision-making, I was fundamentally uncomfortable with adding credence to this type of healthcare. I did not want to be part of the community that perpetuates this approach - the pain may have been alleviated independently of the homeopathic treatment but our friends could still have given us a ‘told-you-so’ nod.

In a wider context, I believe it to be utterly wrong that companies sell and profit from pseudoscientific approaches, given the concerns with these remedies outlined here and elsewhere. Any backing we gave it, either by buying more or telling our friends to give it a go, would fuel this industry and lend weight to its wide availability in pharmacies and through publicly funded health services. It would have cost us more money too, and this additional financial burden may force others to choose between effective and ineffective remedies - something that could be avoided by only making effective treatments available.

Lastly, all of the previous points relate to giving legitimacy to an unfounded treatment for teething pain, but homeopaths and their supporters often make erroneous generalisations about the efficacy of homeopathy. Proponents use their selected ‘evidence’ for homeopathic treatment of one condition to argue, ‘hey, homeopathy works!’, and so seamlessly advocate all manner of dilutions to treat every ailment going. This is as ludicrous as suggesting that just because one drug can successfully treat one type of viral infection, ‘hey, drugs work!’, and so we can use all manner of drugs for all types of infections, without showing individual therapies work.

This last point is particularly dangerous when it comes to treating extremely serious and potentially fatal diseases, such as malaria, HIV/AIDS and cancer. Any credibility people see in homeopathic treatment for one disorder may spill over to influence their decision in treating another disorder, with potentially dire consequences.

I may be getting ahead of myself, but I think I’ll get off this bandwagon while I can.

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This post is a re-working of a version originally posted at The Skeptical Dad.

Attempting to ‘manipulate’ the entire Scottish population?

By Blue Wode

In recent times, the two main UKchiropractic associations, the British Chiropractic Association (BCA) and the McTimoney Chiropractic Association (MCA), have come under intense scrutiny. The BCA was brought to its knees by the misconceived libel case it brought against the science writer and broadcaster, Simon Singh, and, as a direct result of it, the MCA suffered the humiliation of having a confidential email to its members leaked online which revealed that it had urged all of them to take down their websites as they were a real threat to both them and their practices. By comparison, the Scottish Chiropractic Association (SCA) has enjoyed a relatively uncontroversial existence. Until now.

Perhaps not surprisingly, the SCA claims on its website that the majority of chiropractic patients present with musculoskeletal complaints such as lower back and leg pain, neck and mid-back pain, headaches, and shoulder and arm problems. It also says that chiropractic can play a“vital” role in living a healthy lifestyle. Undoubtedly most visitors to its website will view these claims as innocuous and in context; however, they suggest a hidden agenda.

POLITICAL LOBBYING

In June 2011, at the AGM of the Scottish Parliament Cross Party Group on Chronic Pain, Mary Scanlon, Member of the Scottish Parliament (MSP) and Convenor, asked why chiropractors seemed so scarce in Scotland. Her question resulted in a number of clinicians advising her that they had reservations about practices like chiropractic that involved spinal manipulation as they were aware of patients who had developed complications as a consequence of it, and that it generally didn’t help people with chronicpain - indeed it tended to make symptoms worse. Interestingly, Steve Gilbert, National Lead Clinician for Chronic Pain in Scotland, mentioned that any treatment will help a patient where time and attention is enhanced by touch – a view that is consistent with the World Health Organisation’s 2003 bulletin on Low Back Pain.

It’s worth noting at this point that the SCA’s representative on the Group on Chronic Pain didn’t attend its 2011 AGM, or the subsequent meeting in October 2011. Nevertheless, an impressive 76 members of the SCA turned up to rub shoulders with MSPs at a promotional evening on 9th November 2011 at the Scottish Parliament. This wasn’t the SCA’s first time engaging with Scottish Parliamentarians - it had previously enjoyed their hospitality during a visit in the summer of 2010 to raise awareness of chiropractic and introduce MSPs to chiropractic spinal screenings and health checks.

On the day of the November event, Mary Scanlon MSP informed the Scottish Parliament that she thought it “odd that, although chiropractic treatment should be available on the NHS, no GPs refer patients for it”. Perhaps she wasn’t paying close attention during the June 2011 Chronic Pain Group’s AGM when several of its members took a dim view of spinal manipulation. Or perhaps there’s another reason - one that’s not getting through to her and other MSPs, but which, as will become apparent, seems to be understood increasingly by GPs and other healthcare professionals.

PHILOSOPHICAL UNDERPINNINGS

By way of illustration, one need look no further than the website of MSP, Bill Walker, who has had no qualms about publicising an encounter he had with Dunfermline-based chiropractor, Mark Baxter, at the November 2011 reception for the. Mark Baxter told him:

As a proven, cost-effective, regulated Health Care profession, we stand ready to assist the people of Scotland, and Dunfermline in particular, with effective relief from most mechanical back and neck pain related conditions.

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However, Mark Baxter could easily be accused of giving a false impression of chiropractic inScotland. If you take a close look at the photograph that Bill Walker has included on his web page, you’ll notice that beyond the friendly handshake being presented to us lurks something that is altogether very different from the musculoskeletal pain relief line offered by Max Baxter.

Immediately behind the two men, you’ll see a display sporting the SCA emblem on which the following can be clearly discerned:

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‘…URVISION …TO CREATE A VITALISTIC …OPRACTIC MODEL …TH AND …ALTHCARE OF …TIRE NATION.’

Those words are a blatant indication that the SCA favours an outdated model of healthcare above an evidence based one. Indeed one single, damning word, ‘vitalistic’, confirms that the SCA is committed to perpetuating its long-held belief in an implausible concept.

Unfortunately, it is more than likely thatBill Walker, Mary Scanlon, their MSP colleagues, plus a vast swathe of the Scottish population, are unawarethat vitalism is an old, discredited philosophy that proposes that living things possess a non-physical, ‘vital’ energy force. Many chiropractors, however, still believe in vitalism, referring to its metaphysical, non-measurable entity as ‘Innate Intelligence’, a term that is exclusive to chiropractic. Such chiropractors are adherents to the doctrine of chiropractic’s founder, Daniel David Palmer, whohypothesised that a patient could achieve optimal health or ‘wellness’ by allowing the spinal cord to express its ‘Innate Intelligence’ through spinal ‘adjustments’ (often confused with ‘manipulations’) to correct alleged misaligned vertebrae (‘subluxations’ as defined by chiropractors). These misalignments, Palmer believed, caused ‘nerve interference’ that was responsible for triggering most diseases. However, it has been shown to be anatomically impossible for misaligned vertebrae to interfere with the autonomic (involuntary) nervous system and no one has ever been able to demonstrate that subluxations exist or cause disease by theoretically compromising neural integrity.

This vitalistic approach - which usually focuses on detecting and adjusting subluxations as opposed to treating pain symptoms only - is almost certainly why the SCA’s website declares that, in addition to musculoskeletal conditions, chiropractic can play a“vital” role in living a healthy lifestyle. Indeed, this seems to be further confirmed by a previous SCA president’s comments on the results of a General Chiropractic Council (GCC) committee member election:

“…many of the old guard mechanists have been swept out of office and the vitalisticgroup have attained a more democratic and mainstream chiropractic balance. If the younger members, up to 500 of whom did not have a vote because of a quirk in the law, had been able to vote then I believe the swing would have totally unseated the medically oriented mechanists so prevalent on the previous Council. The future is a little brighter for British Chiropractic.”

Sadly, the unwitting patients of vitalistic chiropractors are vulnerable to becoming the victims of what is known as the chiropractic bait and switch:

“…someone may go to see a chiropractor and think they will be seeing a medical professional who will treat their musculoskeletal symptoms, but in reality they will see the practitioner of a cult philosophy of energy healing…The bait — claims that chiropractors are medical practitioners with expertise in the musculoskeletal system. The switch — practitioners of discredited pseudosciences that have nothing to do with the musculoskeletal system…”

Some chiropractors attempt to overcome charges of promoting quackery by substituting the word ‘subluxation’ with other terminology. The SCA, however, seems content to make reference to ‘subluxations’ on its website, although it appears to be carefully worded.

SCIENTIFIC EVIDENCE

But perhaps of greater concern is the SCA’suse of what appears to be a patient compliance and retention gambit with its advice “to get the most out of your treatment, it is important to follow your chiropractor’s recommendations and advice, and also its scientifically meaningless claim that “a growing number of patients are looking for help with more general health conditions and choose chiropractic care to ensure optimal spinal function”. As UK chiropractors are required by law to obtain informed consent from their patients, this assumes that such patients will be made fully aware that there is no good evidence for chiropractic beyond the short-lived relief of pain in patients suffering from acute low back pain. This obligation for transparency obviously presents an ethical dilemma for chiropractors as divulging the slim evidence for spinal manipulation, and the risks of chiropractic, has the potential to deter patients from proceeding with proposed treatments. This is supported by two surveys, one of UK chiropractors, and one of UK and US chiropractors. A large number of chiropractors in these surveys admitted to failing to implement valid consent procedures for a variety of reasons, most of which were not in the best interests of patients.

Although serious adverse events associated with chiropractic treatment appear to be rare, a responsible risk/benefit assessment of most chiropractic manipulative interventions usually arrives at an unfavourable conclusion. Indeed, as Simon Singh said at the end of his article which saw the BCA launch its unsuccessful lawsuit against him:

“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.”

That comment may seem sensationalist, but when you consider that the main risks of chiropractic treatment are not confined to patients suffering from neck pain, it makes perfect sense. What many people do not seem to appreciate is that chiropractors who believe that they are detecting and correcting ‘subluxations’ will often adjust the necks of patients suffering from back pain. The other risks worth considering which are far more common, but often overlooked, are:

“(a) decreased use of immunisation due to misinformation given to parents, (b) psychologic harm related to unnecessary treatment, (c) psychologic harm caused by exposure to false chiropractic beliefs about ‘subluxations’, and (d) financial harm due to unnecessary treatment.”

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Incredibly, despite these concerns, there is no reliable reporting system for harms experienced by chiropractic patients in the UK. This state of affairs is made all the more disconcerting by the content of a draft document on revalidation which was commissioned recently by the GCC (and subsequently dropped). Its purpose was to provide an analysis of the risks and benefits of chiropractic, with the aim of establishing if there was a business case for revalidation. In section 5.72 of the document, the BCA admits that its members have caused patient rib fracture injuries, but in sections 5.13 (along with the MCA), and 5.64, the SCA have apparently ignored the request for details of patient incidents and complaints.

Putting chiropractic pseudoscience and risks to one side brings the cost-effectiveness of spinal manipulation into sharp focus, and based on the data that are in so far, the news is not good. A 2003 review found that, in most instances, manipulative treatments for back pain were more expensive than others (apart from surgery) and not more helpful to outcome, and a major 2006 review found that manipulation for spinal pain normally represented an additional cost to conventional treatment. This factor alone has the capacity to impact negatively on a chiropractor’s ability to earn a living.

By now it should come as no surprise to readers that many GPs in the UK (i.e. not just Scotland) are not referring patients to chiropractors. This is mainly due to dozens of Primary Care Organisations refusing to fund the National Institute for Health and Clinical Excellence’s (NICE) recommendations for spinal manipulation as a first line treatment for low back pain. When the recommendations were originally published, they immediately sparked fierce criticism, not least from other musculoskeletal practitioners, and, to date, as the Ministry of Defence recently reminded a new chiropractic campaign group, chiropractic has not been endorsed by the NHS.

CHIROPRACTIC WARS

Returning once again to the philosophical stance of the SCA, it’s worth mentioning that even the embattled BCA has made it clear that it takes exception to vitalistic practices. Along with the MCA and the United Chiropractic Association (UCA), the SCA recently formed a group called the Alliance of UK Chiropractors (AUKC) and they asked the BCA to join it. However, the BCA refused, objecting to the AUKC’s adoption of the International Chiropractors Association (ICA) Best Practices documentation which, among other policies:

Supports 27 indications for chiropractic radiography (x-rays) including spinal subluxation, birth trauma (forceps), facial pain, skin diseases, organ dysfunction, eye and vision problems, and hearing disorders.

;

Recommends a basic care plan for simple uncomplicated axial pain (neck pain, back pain, etc) consisting of 25 visits over 8 weeks – with the presence of ‘complicating factors’ (including family/relationship stress, lower wage employment, and wearing high-heeled shoes) warranting a recommended additional 12-visit blocks of care.

In particular, the BCA:

“…did not consider a basic 25-visit course of care for uncomplicated back pain to be in the best interests of patients and deemed such practices as being open to allegations of patient exploitation. It also advised that UK chiropractors should not be subjected to US guidelines that are fundamentally incompatible with European law, nor that make recommendations for care that dictate extensive care plans on the basis of flimsy complicating factors.”

BACK TO THE FUTURE

All of the above raises the following question: Could the SCA’s vitalistic outlook be the reason for its representative’s absence at the recent meetings of the Scottish Parliament Cross Party Group on Chronic Pain? Whether it was or not, it is likely that the credibility lent to the SCA by the inclusion of one of its officers on the Group on Chronic Pain will be used to great advantage by it during its intended future discussions with the Scottish Parliament regarding the regulation of chiropractors (ref. item 34 of the GCC’s Communication Advisory Group meeting in December 2011).

These proposed meetings could well be an indication that there is manoeuvring afoot by the SCA to enhance its standing in Scotland in the form of a Scottish Chiropractors’ Act, and/or a ringing endorsement of chiropractic from NHS Scotland (whetherScotlandbecomes independent or not). But even if that is not the case, it is paramount that the SCA’s strong leanings towards vitalistic chiropractic practices are fully understood by as many people as possible - i.e. not just Mary Scanlon, her MSP colleagues, but also the general public, the full spectrum of healthcare professionals, and the media.

In the meantime, elsewhere in the world, chiropractors who avoid science as a basis for their practices are coming under fire from within: In Australia they are being severely criticised for being misguided and irrational; in the United States, James Winterstein, D.C., President of the National University of Health Sciences, has declared that “the subluxation must go” because there’s no evidence for it; and in a recent article in the journal, Chiropractic & Manual Therapies, another academic chiropractor demanded that registration boards…

“…prohibit the common practice whereby potential clients present to a chiropractor for a musculoskeletal complaint, only to be convinced that they are in fact suffering from subluxation related disorders and require prolonged chiropractic care.”

Chiropractic’s day of reckoning will come, but it doesn’t look like it will be any time soon. Indeed, as Simon Singh commented recently regarding the state of chiropractic in theUK in the aftermath of the BCA’s failed lawsuit against him:

I suspect that we are back to square one with chiropractors making all sorts of weird claims and a regulator that is unable or unwilling to take control.”

So, until things are tightened up, be wary of chiropractors wherever you are. It may not only be your spine that they’re out to manipulate.

Further reading

Scottish Parliament Freedom of Information request procedure

Chiropractic overview at Science Based Medicine

Chiropractic articles at Science Based Medicine

Chirobase