It’s quiet…. Too quiet

carry_on_up_the_kyber_4

As the year draws towards its end, what has become of one of the big Alt.Reality stories of the year in the UK – the back-crackers Chiropractors vs. Simon Singh libel action?

Well, legal blogger Jack of Kent has been keeping a weather eye on the procedural bubblings-under of this case, in which the British Chiropractic Association (or BCA) are suing noted science writer Simon Singh for being mean about them.

As those who have been following the case will know, it all stems from a short Opinion piece Singh wrote in the Guardian back in April. In the article he repeated what he and Edzard Ernst had said in their excellent book Trick or Treatment; namely that there is no credible scientific or medical evidence that chiropractic can treat lots of things wholly unrelated to your spine, such as asthma in children, colic in babies, sleeping problems in babies, feeding problems and so on.

All of which claims appear on the British Chiropractic Association’s website here (NB – PDF).

The BCA promptly sued. Which ensured them the undying derision of the Bad Science Blogosphere –see e.g. Holfordwatch’s summary here – and also promulgated knowledge of Singh’s claims, and the BCA’s rather thin-skinned response, across the Interwebs – the so-called “Streisand Effect” or “Spartacus Effect”. Much online discussion ensued, including my own extended (not to say downright longwinded) amateur legal analysis of the ways in which Singh might defend the suit.

Subsequently, all went quiet until about a month ago, when Jack of Kent reported that the BCA’s lawyers had finally detailed how they felt Singh had libelled their clients, and that subsequently Singh and his lawyers had filed their defence, i.e. had outlined the basis on which Singh would seek to defend the action. I was pleased to note, if I may be allowed a bit of self-congratulation, that my analysis of both the libel and of the likely defences had been reasonably close.

One of the most interesting aspects of Singh’s outlined defence is that he does not appear to be proposing to use a simple defence of “fair comment” (in effect, to say that the allegedly libellous bits of what he wrote were his honestly held opinion based on the facts). The filed papers strongly suggest that Singh and his legal team are prepared to “go the distance” and argue justification, i.e. to argue that the remarks Singh made debunking the Chiropractors’ claims were materially true and accurate.

This is interesting, because it is a much more nail-your-colours-to-the-mast position – especially under the plaintiff-friendly British libel laws – than “fair comment”.

As I discussed at length before, a straight “fair comment” defence would probably be the standard newspaper “get-out clause” for defending this kind of libel action. Indeed, in my earlier post I suggested that the BCA might actually be banking on Singh filing a “fair comment” defence:

“I suppose it could be that the BCA are taking the action specifically in the hope that Singh will file a “fair comment defence”, the idea being that they can then issue a ringing public statement arguing that Singh has admitted his comments about the BCA are “opinions rather than facts, by his own admission”. Of course, that would not dispute the facts on which the opinions are based.”

Now, if this was an accurate reading of the mindset of the BCA, then Singh’s filed defence has rather called their bluff. Jack of Kent quotes from the defence brief:

Further or alternatively, insofar as necessary the Defendant will justify the article in the following meanings:

(a) The Claimant [BCA] is …  promoting chiropractic as a treatment for infants and young children with colic or sleeping and feeding problems or frequent ear infections or asthma or prolonged crying [even though]  (as it should be aware):


(i) that there is reliable scientific evidence that this would be ineffective in respect of children with asthma, and/or


(ii) that there is no/no reliable scientific evidence supporting the effectiveness of such treatment for each of those conditions/symptoms, and/or


(iii) that in the circumstances chiropractic treatment for none of those conditions /symptoms is worth the risk of adverse side-effects,


and such treatment is to that extent bogus.”

(one or two minor edits to hopefully reduce the risk of my being sued – you can see Jack of Kent’s blog for the unexpurgated version)


Jack comments:

”As the onus will be on Simon Singh to demonstrate these factual justifications, again the trial will deal fully with expert evidence and cross examination as to the efficacy of Chiropractic.”

Later, Jack spells it out again:

“For the BCA to fully meet Simon Singh’s defence means that the efficacy of Chiropractic in respect of six children’s ailments will require scrutiny by the court, cross-examination of experts, and the testing of the validity of the “scientific evidence” which the BCA cites in support of the efficacy of Chiropractic.

As I said above, the real effect may be to put Chiropractic on trial before the English High Court.

This offers the tantalizing prospect of a series of eminent scientific and medical figures, like Directors of the Cochrane Collaboration, Professor Edzard Ernst, Professor David Colquhoun, and Professor Michael Baum, all trooping into the High Court. Firstly to explain the nature of scientific evidence, and how it is assessed and synthesized, and secondly to set out why the state of the scientific and medical evidence does not support many of the claims made by chiropractors for chiropractic.

Would the BCA, one wonders, really want to have a libel case defended on this basis heard, doubtless over many days, in the High Court in the full glare of the media?

Well, at the moment we don’t really know – because:

It has all gone quiet – very quiet.

In particular, Jack of Kent notes that the BCA and their lawyers have not filed a “Reply” to Singh’s defence. As I am not a lawyer, I am a bit hazy as to the precise point of this “Reply”. However, one possible use of such a Reply, I surmise, could be to allow the BCA’s legal team to dispute whether any of Singh’s proposed modes of defending the action are allowable, or arguable, in law. Again speculating, it could allow them to argue the legal niceties of whether what Singh says he meant (which interpretation makes his words less libellous in law) is less plausible than what they (the BCA) contend his words would usually be taken to mean.

If that sounds a bit convoluted, then it is probably because I’m not explaining it very well. But essentially, a lot of the case might conceivably reduce to what the word “evidence” is commonly taken to mean in the context of a discussion of the “evidence” supporting a treatment. Singh will almost certainly argue that when someone says “evidence” this way – when he said it – it means “the balance of the scientific evidence, scientifically assessed for believability and combined by techniques like scientific review and meta-analysis – which is the way scientists and doctors would do it”

The BCA are likely to argue that evidence means “any evidence, including equivocal or poorly done trials, case reports, customer testimonials, and other evidence which scientists and doctors regard as wholly unreliable.”

Now, if you were the BCA, you might wish to dig out a lot of legal precedents – assuming you could find some – that said that the courts take “evidence” to mean de facto “absolutely any sort of evidence at all” rather than “the balance of scientific evidence”. And you might want to put these arguments in the “Reply” to head off Singh’s defence in advance – sort of:

“You can’t argue the word “evidence” commonly means what you wish it to mean here, because it’s meaning in this context is already well established in law, and it’s what we have been saying it means – so you cannot mount your defence on this point.”

Now, as I am not a lawyer, all of this last bit could be a load of utter nonsense. If so, hopefully Jack of Kent or someone else better informed will come along and put me right.

However: whatever the precise legal purpose of the “Reply”, to date a ”Reply” has not appeared. Jack of Kent’s piece makes clear that this is rather unusual for a case of this type. Jack runs through some possible reasons for the missing “Reply” here.

Will they… Won’t they… Will they… Won’t they…

I have always doubted myself that the BCA would really want this one to go the distance. If I were the BCA’s spin doctor, I would probably be telling them to try and think of a way of staging a tactical retreat, whilst simultaneously claiming that they had been vindicated. However, murmurings emerging from Chiro-world, as briefly chronicled by Jack of Kent, seem to suggest that some voices at least within the BCA think they have to carry on to the bitter end in order to “defend the reputation of the profession”.

To which one might respond – “Err…?”

Now, one could perhaps usefully ask at this point what the general view on chiropractic is among practicing health-care folk, as opposed to among the academic ninjas of evidence-based medicine like Ernst and Colquhoun.

Well, among the medical doctors I know well, the consensus view on chiropractic seems to be roughly that summarized by American physician (and noted medical blogger) PalMD here:

“I am often asked my opinion of chiropractic care. My usual answer (based on evidence) is that it can be somewhat helpful in the treatment of low back pain. That’s it. Any further claims are complete and utter …”

see Pal MD’s post for the rest. It is well worth a read.

It also bears repeating that Professor Edzard Ernst himself, co-author with Simon Singh of the book from which Singh’s disputed claims arise, is not just one of the world’s foremost experts on the assessment of evidence for and against “Complementary Therapies”. He also has long had a special interest in “spinal manipulation therapies”, of which Chiropractic is one. This almost certainly reflects Ernst’s background as a rehabilitation physician. Prior to taking up the Complementary Medicine Chair in Exeter in the mid-90s, Ernst was the Head of the Department of Physical and Rehabilitation Medicine in the University of Vienna’s Medical Faculty. This would mean he is very familiar with physical therapies, probably including spinal manipulation therapies. He may even have trained to carry out spinal manipulation on patients.

It must be highly doubtful, to put it mildly, whether the BCA will be able to find anyone with a matching level of expertise and credibility to argue that Ernst’s damning assessment of the scientific evidence regarding their more outlandish claims is incorrect.

So who thought up all this back-cracking business?

Another thing that might not help Chiropractic is that a high-profile court case would be expected to trigger some media stories exploring their beliefs. It is a fair assumption, I think, that a setting out of the origins, history and philosophy of Chiropractic would not help the BCA’s credibility, either in court or on the wider world. A neat and amusing summary of some of this history was given by Private Eye, which covered the Singh libel case earlier this month:

chiro-extract

All hardly likely to cast Chiropractic in a flattering light,  I would say.

A further intriguing point is that this is all happening at a time when spinal manipulation for lower back pain (something practised by several different groups of practitioners, including chiropractors) is fairly widely available, and viewed as a reasonably mainstream intervention.  If I were the back-crackers, this is just the time when I would be keeping a low profile and trying desperately not to look like a bunch of quacks, cranks, and loonies.

Hence my doubts that the case will go the distance.

But…but…

But – it is a predictable part of the mindset of many Alternative Practitioners, and of their “professional organizations” too, that they have little or no self-insight in certain key respects.  Specifically, they have no insight into either the intrinsic silliness and implausibility of their beliefs, or the central sticking point of their repeated refusal to engage with actual evidence on the key question of efficacy.

It seems constitutionally beyond them to understand that the basic reasoning in healthcare has to be:

“Well, the evidence that [insert your therapy of choice] works for X is reasonable… but the evidence that it works for Y is much dodgier, and near to non-existent, and it is pretty clear-cut that it doesn’t work at all for Z, and might even be harmful… so we should stick to offering it for X, and should discourage our wackier practitioner brethren from offering it for Y and definitely for Z.”

Don’t, though, expect to get this kind of logic from full-on Alt.Reality merchants like the homeopaths. The vast majority of them simply cannot get their heads round this kind of thinking, whatever soothing noises they may make for public consumption.

To repeat for the umpteenth time: They believe it works.

Evidence, schmevidence. They believe. They know.

And as a corollary, many of them seem to believe their therapy of choice will work for nigh-on everything, from asthma, to a bad back, to a blocked nose, to depression, to pre-menstrual tension.

Again, careful sifting of evidence, condition by condition – who needs it?  We just know.

And finally…

Chiropractors are regulated by professional bodies. They are a registered healthcare profession. That, it seems to me, is part of why they are suing Singh.  Their sense of their own gravitas has been offended.

But: judging from these claims the BCA make for chiropractic “treating” all sorts of things that have nothing whatsoever to do with your back – and if one takes it that many of their members will be offering these treatments –  it would not appear a stretch to argue that many chiropractors seem to struggle to recognize where the limits of effectiveness of chiropractic lie.

And if anyone points this out? They sue.

Now, I would expect a “registered healthcare profession” to argue claims about their therapy, and the evidence supporting it, in the scientific and medical literature.

To quote (again) the Editor of the New Zealand Medical Journal, Prof Frank Frizelle, when the New Zealand Chiropractic Association recently threatened to sue him, his journal, and his authors:

“Let’s see your evidence. Not your legal muscle”.

However… given their sense of wounded dignity, we may yet see the BCA’s lawyers and Simon Singh’s lawyers facing off in the High Court. In which case we stand to get both “legal muscle”, and evidence.

Personally, I shall be looking forward to it.

[BPSDB]

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35 Responses to “It’s quiet…. Too quiet”

  1. dvnutrix Says:

    It’s difficult. It’s not in the context of a libel trial but some time ago I know of a trial that involved differences of opinion as to the nature of evidence and experts ranged on both sides. Judging by his summary and comments, the judge did not seem to follow the science too well.

    I take your point that the chiropractors may find it difficult to field some appropriate experts. I wonder if the chiropractors are considering whether they can run a defence that drags in some of the elements from the US case. Judge Getzendanner ruling on Wilk v. AMA commented:

    The plaintiffs, however, point out that the anecdotal evidence in the record favors chiropractors. The patients who testified were helped by chiropractors and not by medical physicians. Dr. Per Freitag, a medical physician who associates with chiropractors, has observed that patients in one hospital who receive chiropractic treatment are released sooner than patients in another hospital in which he is on staff which does not allow chiropractors. Dr. John McMillan Mennell, M.D. testified in favor of chiropractic. Even the defendants’ economic witness, Mr. Lynk, assumed that chiropractors outperformed medical physicians in the treatment of certain conditions and he believed that was a reasonable assumption. The defendants have offered some evidence as to the unscientific nature of chiropractic. The study of how the five original named plaintiffs diagnosed and actually treated patients with common symptoms was particularly impressive. This study demonstrated that the plaintiffs do not use common methods in treating common symptoms and that the treatment of patients appears to be undertaken on an ad hoc rather than on a scientific basis. And there was evidence of the use of cranial adjustments to cure cerebral palsy and other equally alarming practices by some chiropractors. I do not minimize the negative evidence. But most of the defense witnesses, surprisingly, appeared to be testifying for the plaintiffs. Taking into account all of the evidence, I conclude only that the AMA has failed to meet its burden on the issue of whether its concern for the scientific method in support of the boycott of the entire chiropractic profession was objectively reasonable throughout the entire period of the boycott. This finding is not and should not be construed as a judicial endorsement of chiropractic.

    Singh may be on firmer ground as there are specific, named conditions involved – who knows. It will be interesting to see how this plays out.

  2. Alec McEachran Says:

    Just a minor point: there is no “English High Court”, though there is a British one. In my opinion Bad Geography is no less of a sin than Bad Science. Otherwise, thanks for the article.

  3. Blue Wode Says:

    Thanks for an excellent post.

    It’s going to be interesting to see what impact the outcome of this case – presuming it goes ahead and Simon Singh wins – will have on the regulation of chiropractic.

    Currently the scope of practice for chiropractors in the UK is not defined, although section A2.3 of the General Chiropractic Council’s Standard of Proficiency states clearly that “chiropractors’ provision of care must be evidence-based”. In addition to that, the Council requires that “if chiropractors, or others on their behalf, do publicise the information used must be factual and verifiable. The information must not be misleading or inaccurate in any way.” See here:

    http://dcscience.net/nzmj-ernst-reply-050908.pdf

    It’s also worth noting that Section 5.14 of The House of Lords Select Committee Report on Complementary and Alternative Medicine states that a feature of *effective* regulation is”…to understand and advertise areas of competence, including limits of competence within each therapy”. See Chapter 5 here:

    http://www.parliament.the-stationery-office.co.uk/pa/ld199900/ldselect/ldsctech/123/12307.htm

    However, a recent survey of UK chiropractors revealed that traditional chiropractic beliefs (chiropractic philosophy) were deemed important by 76% of the respondents, with 63% of them considering the (fictitious) chiropractic subluxation to be central to chiropractic intervention. The survey is well worth a read…

    http://tinyurl.com/599vfs

    [Aranka Pollentier and Jennifer M. Langworthy, Clinical Chiropractic, Volume 10, Issue 3, Pages 147-155. Sept. 2007]

    …as its overall findings are indicative that the General Chiropractic Council is failing greatly in its duties to protect patients and set standards.

  4. draust Says:

    Just a minor point: there is no “English High Court”, though there is a British one.

    Actually, I think we’re both wrong, Alec It is the High Court of England and Wales. The Scots have their own court system, and I assume Northern Ireland does too.

  5. Stuart G Hall Says:

    I suggest Simon Singh enlists the help of the public health experts at NICE.

  6. Blue Wode Says:

    Stuart G Hall wrote: “I suggest Simon Singh enlists the help of the public health experts at NICE.”

    That could prove more of a hindrance than a help since NICE recently proposed chiropractic spinal manipulation as a first-line treatment in its draft guidelines for the treatment of acute low back pain. Here’s what Professor David Colquhoun had to say about the matter:

    Quote:

    “The inclusion of chiropractic spinal manipulation in the recommendations seems to be to be without foundation. The evidence is surely now rather strong that chiropractic is no more effective than other sorts of manipulation, but it has three disadvantages that should preclude its recommendation

    (1) The (admittedly small) risk of stroke (which has resulted in legal action in several countries)

    (2) The excessive use of X-rays to search for purely imaginary “subluxations”.

    (3) The fact that it is based on mystical, indeed quasi-religious, “principles”. If it is recommended that carries the consequence that its practitioners are required to be ‘educated’ in anti-scientific nonsense.

    Since it has no demonstrated advantage over other approaches, these three reasons are surely sufficient for it to be not recommended. In my view NICE should go further and recommend AGAINST use of chiropractic.”

    http://dcscience.net/?p=258#comment-3663

    Dr Aust wrote: “Ernst was the Head of the Department of Physical and Rehabilitation Medicine in the University of Vienna’s Medical Faculty. This would mean he is very familiar with physical therapies, probably including spinal manipulation therapies. He may even have trained to carry out spinal manipulation on patients.”

    Yes, Professor Ernst has been trained in spinal manipulation and has applied it clinically. See the end of his Systematic review of case reports of serious adverse events following manipulation of the cervical spine (1995–2001) here:

    http://www.mja.com.au/public/issues/176_08_150402/ern10520_fm.html

  7. SciencePunk Says:

    I’m a little worried – science shouldn’t be settled in the courtroom, surely? Testimony, after all, is dangerously close to anecdote.

  8. zeno Says:

    Dr Aust and Alec McEachran: It is probably being a bit pedantic (and really irrelevant to the chiropractic nonsense), but in England and Wales it is the High Court of Justice and the High Court of Justiciary in Scotland. I suspect they are, essentially, very similar, and have a similar purpose but it is properly not wrong to say the ‘English High Court’, particularly when it is likely to be a case under English law.

  9. UK quackery on trial | Bad Astronomy | Discover Magazine Says:

    [...] it doesn’t look like that’s what Singh is doing– he and his legal support have turned the tables on the BCA, and are saying that in fact what Singh wrote is true: a lot of chiropractic practices are bogus [...]

  10. Jack of Kent Says:

    Thanks for the links, Dr Aust. The next step will be to get hold of any “Reply” by the BCA. The full trial should come before the summer. I now understand also that, like the Irving trial, it will be WITHOUT a jury.

    And Alec – thanks for the most barmy “correction” I have seen for ages. It is indeed the English High Court.

  11. UK quackery on trial - The WebZappr Says:

    [...] an easy solution that gets the job done. it doesn’t look like that’s what Singh is doing– he and his legal support have turned the tables on the BCA, and are saying that in fact what Singh wrote is true: a lot of chiropractic practices are bogus [...]

  12. Michael Cross Says:

    There is a precedent for a libel case establishing the truth to the discomfort of plaintiffs. When the ‘historian’ David Irving sued Penguin Books, the publisher’s robust – and expensive – defence laid bare Irving’s record as a holocaust-denier. The story is excellently told in Richard Evans’ Telling Lies about Hitler.

  13. draust Says:

    Thanks to all for the interesting comments, and especially to Blue Wode for the pointers to additional info on Chiropractic and its official practise standards. I have been having a bit of a Christmas blogging slowdown, but I will discuss some of the comments in an extended response, either here or as a new post, and hopefully in the next couple of days. A few quick thoughts:

    The bits Blue Wode quotes from the General Chiropractic Council’s literature are very interesting. As the GCC is a statutory body established by an Act of Parliament it would not, as I understand it, be able to sue someone for defamation. So I wonder what would have happened if Simon Singh had said “Chiropractic” (in general) supports treatments for which there is no evidence base, rather than saying “the BCA…?”. The GCC would not be able to sue, and it would probably be harder for the BCA to claim they had been libelled than with the form of words Singh actually used. Another one for the lawyers.

    I agree with Sciencepunk/Frank that the courts aren’t really the place to settle issues of medical/scientific fact and evidence. However, if people and organisations attempt to use the defamation laws to gag debate, then under current British law the question of where the debate should happen necessarily moves to the courts. In effect, the evidence for chiropractic in treating these conditions is going to be argued out in the High Court precisely because the BCA do not wish it to be argued anywhere. That is, it seems to me, the underlying principle.

    The David Irving vs. Lipstadt/Penguin libel case that Michael Cross mentioned is an interesting parallel. The case utterly destroyed Irving’s reputation mainly because the forensic work of Professor Richard Evans and his students showed that Irving had been a “career-long falsifier” – i.e. everything he had ever written, including his earlier purportedly scholarly historical works, were riddled with misquoting, selective citation and pro-Hitler bias. Irving’s extensive Wikipedia entry is a good introduction for those who have not come across the man before.

    The Irving vs Lipstadt case has personal resonance for me, because when I was a kid we had a copy of Irving’s first, and reputation-making, 1963 book The Destruction of Dresden on the bookshelf.

  14. Jack of Kent Says:

    “So I wonder what would have happened if Simon Singh had said “Chiropractic” (in general) supports treatments for which there is no evidence base, rather than saying “the BCA…?”. The GCC would not be able to sue, and it would probably be harder for the BCA to claim they had been libelled than with the form of words Singh actually used. Another one for the lawyers.”

    Correct.

  15. First Skeptics’ Circle, 2009! « Bug Girl’s Blog Says:

    [...] Aust has an update on the Simon Singh Case, and Space City Skeptics explain how to design your woo study to get the proper false positive [...]

  16. Blinks18-medstu Says:

    In relation to Singh’s article, he states that “conventional therapy is still preferable because of the serious dangers associated with chiropractic” however a medical risk is considered 1:10,000 statistics have shown that the risks of having a stroke from a cervical adjustment in chiropractic (perhaps the biggest accusation at chiropractic) are around 1:1,000,000 or something around that nature (although most statistics are fiddled or made up) which bares a similar resemblence to the normal population suffering from a stroke. Chiropractic treatment is proven to alter blood flow after treatment, this does not mean it will result in a stroke. Atherosclerosis could already be present within the arteries which as a result of poor lifestyle could be a waiting time bomb for a patient.

  17. Svetlana Says:

    Medical risk is 1:10,000 (1:1,000,000)??? Where has this person taken the data from?? The reference, please!

  18. Svetlana Says:

    Dr. Aust, where are you? You have vanished to somewhere… ;)
    Probably, you are busy. Though I see you sometimes in other’s blogs.

  19. draust Says:

    Yes, February has been incredibly busy/fraught both at the office and at home, as I have indicated over at the diary page. Have not been able to summon the energy/focus to finish any substantial posts – quick comments at other blogs are easier, and more of a relaxation…

    Anyway, hopefully March will be a bit quieter and I can finish a few things off for the blog.

  20. Svetlana Says:

    OK! We are waiting for new posts!..

  21. draust Says:

    Apropos of the comment from “Blinks18″ about Edzard Ernst, chiropractors and the risk of stroke with chiropractic neck-wrenching, there is a discussion where this turns up going on over at one of Orac’s old threads at Respectful Insolence.

    The relevant thread is here, and the bit to look at is the last two dozen or so comments, notably those by “another Chiropractic physician” (for Chiropractic, natch) and by “Robster FCD” (who I think is a toxicologist), plus occasional others, putting the sceptical view.

    The thread actually started as a rather innocuous discussion about who was allowed to call themselves “Doctor”, but it seems I triggered the “segue” to Chiropractic by putting up a link to the recent Economist article/discussion thread on CAM.

    My personal view is that both threads exemplify how the Chiros – in common, it must be said, with most practitioners of the other Alt.Health professions – are constitutively incapable of self-critique. As indeed does the BCA vs. Singh libel case.

  22. draust Says:

    Also following from what Blinks18 said:

    Atherosclerosis may well be present in the arteries (including those in the neck) in older folk, but if I had plaques in my arteries I don’t think I would want someone wrenching my neck about. In particular, I can’t imagine abrupt changes in blood flow through an artery are likely to be desperately good news if you have an unstable plaque in there. So atherosclerosis sounds to me like yet another reason to avoid letting a chiropractor near your neck.

    Can I direct you again to Pal MD’s pithy summary cited in the original post:

    “I am often asked my opinion of chiropractic care. My usual answer (based on evidence) is that it can be somewhat helpful in the treatment of low back pain. That’s it. Any further claims are complete and utter …”

  23. DrAbraham Says:

    Although when thinking of a chiropractic treatment, the majority of people in the country think of the treatment of back pain or neck pain. Chiropractic however is currrently one of the most primary forms of general diagnosis within a patient. If say a patient therefore presents with atherosclerosis or ‘unstable plaque’, therefore the adjustments or treatment will obviously not be carried out. However if the patient already knows that he has the ‘unstable plaque’ present prior to the appointment, then it should not be left out of the case history and will not be overlooked. The integratory of the treatment therefore if missed will not be and should not be the profession, but the clinician, just as if a poor doctor or medic may give a wrong prognosis or prescription. That therefore should be the person under investigation to maintain standards. Can I just add an interesting point; according to one of the journals posted on the WCA website, the chance of a CVA occuring due to a cervical manipulation has the probability as a CVA occuring due to a patient leaning back over a sink in a hair salon to have their hair washed.

  24. Blinks18-medstu Says:

    In return to Dr. Aust’s comment, I’d like to point out that many patients with atherosclerosis in their neck may not be aware that there are plaques present. Therefore if they presented with neck pain, unaware, surely it is unlikely that the practitioner would know also. However the point of “abrupt changes of blood flow” after chiropractic treatment is exaggerated.

  25. draust Says:

    I take Dr Abraham’s point about a person with obvious atherosclerotic disease being contra-indicated for neck manipulation, though I would need convincing that UK chiropractors would be that cautious… and it wouldn’t always be that obvious. I would be interested to see the actual reference s/he refers to in terms of the relative risk of other kinds of neck movement.

    Re. the likelihood of CVAs after neck manipulation or other things, this is one of the long-running hot issues with the safety of chiropractic. Like some other people I am troubled by the occurrence of CVAs after neck manipulation in younger patients – see e.g. the discussion here.

    And concerning:


    “…the majority of people in the country think of the treatment of back pain or neck pain [as reasons to consult a chiropractor]“

    Perhaps – but it is a pretty regular thing to see newspaper “holistic health columns” in the UK touting chiropractic manipulation for all kinds of other stuff. And as the Singh case shows, the chiropractic professional associations seems happy to endorse it for many things beyond back pain, and wholly unrelated to spinal / musculoskeletal problems.

    Finally, “word on the street” (or at least on Facebook) is that the game is afoot with the Singh case. More news as we get it.

  26. British Chiropractors vs. Simon Singh: what next? « Science Notes Says:

    [...] monado A “grumpy scientist” at Dr. Aust’s Spleen weighs the positions in the BCA’s libel suit against science writer Simon Singh, and wonders if they’ll force him to prove in court that there’s no good, scientific [...]

  27. monado Says:

    Well, the creationists in the U.S. defending Kitzmiller vs. Dover were full of confidence, too. They lapped up Michael Behe’s assertion that a pile of textbooks and peer-reviewed journals describing the steps in evolution of blood-clotting or immune systems or flagellae was not enough evidence to convince him that it happened, and he retired from the stand in a glow of satisfaction. However, it didn’t satisfy the judge.

  28. Xerglacia Says:

    To add to what DrAbraham and Blinks18 have said, here’s a news story and the study it relates to which conclude that chiropractors don’t raise the risk of stroke (compared to visiting the person’s primary care physician).

    Story: http://www.theglobeandmail.com/servlet/story/RTGAM.20080119.chiro19/BNStory/specialScienceandHealth/home
    Study: http://www.mrw.interscience.wiley.com/cochrane/clcentral/articles/061/CN-00643061/frame.html

  29. draust Says:

    The study in Spine by Cassidy et al. that Xerglacia (and the Globe and Mail article) are talking about is the one discussed in the thread that I linked to in a comment above on Science Based Medicine: link to the thread again here.

    As ever, there are studies, there are critiques of studies, and there are critiques of the critiques. Apart from the SBM thread, another extended discussion of the evidence on this area can be found over at Respectful Insolence on the monumental thread that I already linked to here (look down towards the last 30-40 comments).

    I personally find the refusal of the chiropractic fraternity to engage with the details – and often to entertain the mere idea that chiropractic might be associated with VBA stroke – telling. “That’s ridiculous!” they bluster. “Prejudice!” But it is fair to say that the chiropractors see it differently. It is also fair to say that I tend to be on the side of mainstream medicine in the CAM vs. mainstream debate, and that a chiropractor would therefore say I am biased.

    Apart from what I’ve just said about the chiros (in common with most CAM-mers) having a systemic problem with self-critique, I find the arguments from the mainstream more convincing because the people making them seem to me to have a far, far greater understanding of statistical and inferential methods, and their limitations, and far more clinical / medical insight, than the pro-chiro lot. But again, that’s just my personal view.

  30. draust Says:

    As an aside, the riposte from chiro (and, again, other CAM) types on the blogs often – far too often, if you ask me – tends to be along the lines of:

    “You are not a chiropractor [homeopath/herbalist] and not a clinician so you cannot possibly understand what you are talking about.”

    As a personal example, a few months back a chiropractor emailed me with a lengthy response which said, inter alia:

    “Are you a clinician? As a chiropractor I am a licenced primary care provider and can give people CPR, like I did on a plane ride recently. Can you do that?”

    ..and so on. How this was relevant to my ability to understand statistics, clinical trials, the science (or not) behind CAM modalities or the evidence for or against CAM, was not vouchsafed.

  31. Xerglacia Says:

    After reading through the link to the response to the study and the exceptionally long replies to it, it seems like the only way that this could be “proven” to the point that both sides would agree (and that I still doubt after all those responses) would be to take a large number (100,000 to 1,000,000 just so that there might be enough evidence, since the stroke risk is apparently 1:1,000,000 or so) of young (20-45 year old) people, put a tracer in their blood, x-ray or image the blood vessels in their neck, perform the manipulations by a number of registered and fully practicing chiropractors (this way the chiropractors can’t say that it wasn’t a chiropractor performing the manipulation or that they were inexperienced) and then wait 5-30 minutes (just to make sure that if it were to occur, it would have a chance to manifest itself or show signs that it might) and then x-ray or image the blood vessels again.
    Also, the same thing would need to be done without the actual thrust, so the neck is turned to the side as a control group. (And we already have statistics on people who don’t receive the chiropractic care)
    The x-rays would then have to be given to a completely different group of doctors to read them so that they could simply go one what they saw on the x-rays without knowing anything else, hopefully decreasing any potential bias that might happen if they were part of the initial x-ray/manipulation portion of the trial.

    With “photographic” evidence, it would be far more difficult for either side to refute any findings, even though I’m sure the side that believe the study to be wrong would try. (Whichever side that is, it would be up to the study to show that.)

    Also, this says nothing about whether the actual adjustments/manipulations have any benefit, but would at least settle the debate as to whether stroke is actually caused by chiropractic care.

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