"Beware the Spinal Trap"

Wednesday, July 29, 2009

You all know I'm a fan-girl of science and the Constitution. So when the BCA sued Simon Singh for saying that chiropractic is "bogus," I was all over the bandwagon to support his free speech (yes, I know he's English. Yes, I know "free speech" and "libel" are looked at differently in England than they are here. But I believe that truth should always be an acceptable defense).

So in that spirit, I'm joining blogs all over the Internet in reposting Simon's article that started the hullaballoo. The article below has been cleaned up by lawyers to prevent the BCA from suing a shitload of other bloggers (unlikely, but I've been threatened with lawsuits over less). However, Orac has helpfully posted the entire article and bolded the sentences that were removed by the lawyers.

Stay strong, my brother.

Beware the Spinal Trap

Some practitioners claim it is a cure-all, but the research suggests chiropractic therapy has mixed results – and can even be lethal, says Simon Singh.

You might be surprised to know that the founder of chiropractic therapy, Daniel David Palmer, wrote that “99% of all diseases are caused by displaced vertebrae”. In the 1860s, Palmer began to develop his theory that the spine was involved in almost every illness because the spinal cord connects the brain to the rest of the body. Therefore any misalignment could cause a problem in distant parts of the body.

In fact, Palmer’s first chiropractic intervention supposedly cured a man who had been profoundly deaf for 17 years. His second treatment was equally strange, because he claimed that he treated a patient with heart trouble by correcting a displaced vertebra.

You might think that modern chiropractors restrict themselves to treating back problems, but in fact some still possess quite wacky ideas. The fundamentalists argue that they can cure anything, including helping treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying – even though there is not a jot of evidence.

I can confidently label these assertions as utter nonsense because I have co-authored a book about alternative medicine with the world’s first professor of complementary medicine, Edzard Ernst. He learned chiropractic techniques himself and used them as a doctor. This is when he began to see the need for some critical evaluation. Among other projects, he examined the evidence from 70 trials exploring the benefits of chiropractic therapy in conditions unrelated to the back. He found no evidence to suggest that chiropractors could treat any such conditions.

But what about chiropractic in the context of treating back problems? Manipulating the spine can cure some problems, but results are mixed. To be fair, conventional approaches, such as physiotherapy, also struggle to treat back problems with any consistency. Nevertheless, conventional therapy is still preferable because of the serious dangers associated with chiropractic.

In 2001, a systematic review of five studies revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches. These are relatively minor effects, but the frequency is very high, and this has to be weighed against the limited benefit offered by chiropractors.

More worryingly, the hallmark technique of the chiropractor, known as high-velocity, low-amplitude thrust, carries much more significant risks. This involves pushing joints beyond their natural range of motion by applying a short, sharp force. Although this is a safe procedure for most patients, others can suffer dislocations and fractures.

Worse still, manipulation of the neck can damage the vertebral arteries, which supply blood to the brain. So-called vertebral dissection can ultimately cut off the blood supply, which in turn can lead to a stroke and even death. Because there is usually a delay between the vertebral dissection and the blockage of blood to the brain, the link between chiropractic and strokes went unnoticed for many years. Recently, however, it has been possible to identify cases where spinal manipulation has certainly been the cause of vertebral dissection.

Laurie Mathiason was a 20-year-old Canadian waitress who visited a chiropractor 21 times between 1997 and 1998 to relieve her low-back pain. On her penultimate visit she complained of stiffness in her neck. That evening she began dropping plates at the restaurant, so she returned to the chiropractor. As the chiropractor manipulated her neck, Mathiason began to cry, her eyes started to roll, she foamed at the mouth and her body began to convulse. She was rushed to hospital, slipped into a coma and died three days later. At the inquest, the coroner declared: “Laurie died of a ruptured vertebral artery, which occurred in association with a chiropractic manipulation of the neck.”

This case is not unique. In Canada alone there have been several other women who have died after receiving chiropractic therapy, and Edzard Ernst has identified about 700 cases of serious complications among the medical literature. This should be a major concern for health officials, particularly as under-reporting will mean that the actual number of cases is much higher.

If spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.

Simon Singh is a science writer in London and the co-author, with Edzard Ernst, of Trick or Treatment? Alternative Medicine on Trial. This is an edited version of an article published in The Guardian for which Singh is being personally sued for libel by the British Chiropractic Association.


H/T to Skepchick for passing the torch.

25 comments:

The Mechanicky Gal said...

I am going to revive Phrenology. It totally will determine who will become a criminal.
Really!

Janiece Murphy said...

::snort::

mom in northern said...

Do you think introductions to the anti-vaccine lady would be approperate?

Jim Wright said...

I am going to revive Phrenology


How about active phrenology, Mechanicky Gal - that's where instead of passively reading the skull bumps, you put lumps on someone's skull. With a stick.

I'm thinking this is a case where something like that would be appropriate.

Janiece Murphy said...

"Get in the fucking sack."

Juan Federico said...

Hey Murph? That whole get in the sack comment........Orale!

Steve Buchheit said...

Um, shenanigans. Yes, it is not a cure all. In 1860 many doctors claimed their treatments were a cure all. Surgeons claimed they could cure all ailments by surgery. Drug therapy proponents still say they will eventually cure all ailments with a pill or drug/pharmacological therapy. See the current claims of genetic therapy and stem-cell therapy proponents. As for treatment and claims made in the 19th century by "doctors" of all stripes. Please. At the time the germ theory of disease hadn't been accepted yet either.

I've been to three chiropractors over the years, none of them make that claim. The one chiropractor I've had the longest relationship did referred me to another doctor for a problem I had because he couldn't help me. BTW, he does hold a medical degree and is licensed to practice by the state (http://chirobd.ohio.gov/).

"experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches" - sounds like every drug therapy side effects lists. And franky, every time I've been to the chiropractor I've gone in the door with at least two of those.

"700 cases of serious complications" over what period of time? And what is listed as "serious"? How large was the sample? And how does those numbers compare to other therapies? He makes a rhetorical argument, but doesn't back it up.

"there have been several other women who have died after receiving chiropractic therapy" And what were the causes of those deaths? Were they related to the therapy or to the underlying condition of which they went to therapy or to some other condition?

Plus he admits that it can help treat some conditions and has as much success as other techniques (such as physiotherapy, which if memory serves, includes spinal manipulation and other techniques used by chiropractors). So his claim of "bogus" may not be so defensible.

neurondoc said...

Jinx! A bit late, but it must be said. Your post has more traffic and phrenology. :-) I'm jealous.

As always, one can get some good data and perspective from Science Based Medicine.

As I said in my post, I've seen two strokes from vertebral artery occlusion within hours of chiropractic manipulation of the neck from two different chiropractors. If I saw two, I can only imagine that serious adverse events are under-reported.

I love the concept of active phrenology. I may have to use that as a threat at work.

Janiece Murphy said...

Steve, I assume you have scientifically sound, double blind studies to back up your comments? Because the BCA certainly didn't, and neither does any other chiropractic organization that I've ever read about. Please note that such studies must have the same standard of quality that the FDA requires in order to do an apples to apples comparison.

The point here is not that drug therapy per se is the end-all or be-all of medical research. To quote Dara O'Briain, science doesn't claim to know everything, otherwise it would stop. The point is that chiropractic has never been shown to be effective in most of the areas that they claim (colic, etc.), and that other therapies have a much more stringent standard of risk to efficacy than chiropractic. Your anecdotal commentary about your personal experiences with M.D.'s and ethical chiropractors (without listing the corresponding studies) presents a logical fallacy that is hardly up to your usual standard of argument.

So, yes, shenanigans, but probably not in the way you meant.

Janiece Murphy said...

I also want to add that the BCA didn't sue Mr. Singh for any of the assertions or comments made in this revised article. They sued based on the redacted commentary that you can find in Orac's reprint, linked in the post. The claims in this post went unchallenged in English court.

neurondoc said...

The plural of anecdotes is NOT data...

John the Scientist said...

Steve, you have a couple of faulty arguments.

First, the rates of adverse events. Certainly most drugs have this laundry list of possible AEs, and this is because a certain percentage of the population has those symptoms spontaneously every day, but if they are in a clinical trial, it is assumed that the AE is due to treatment. Hence the absurdly long lists of possible effects in Direct to Consumer ads on TV.

However, the rates are also important. Event rates greater than 5% tend to be real, if insignificant or transient. Event rates greater than 10% are almost definitely real and due to treatment (rules of thumb, I am sure Natalie is familiar with Hy's Law, which is for severe liver enzyme elevations and can sink a treatment even if only one or two cases appear).

The event rates for chiropractic reported in the literate are 50%. Even if all the events were mild and transient, few doctors would prescribe, and perhaps the FDA would not approve, a treatment with that kind of event rate.

Natalie and I are upset about chiropractic because the anti-science attitude of the general population accepts that kind of danger signal from a bogus treatment developed by a kook. Whereas vaccines are bad for you because they are artificial chemicals you put in your body, with event rates smaller than chiropractic by orders of magnitude.

Second, when you ask for sample size, you didn't read the context. After launch or acceptance, treatments are not followed in a systematic way in the general medical literature, but physicians do publish case studies in journals as a way to show early warning signals to other physicians. One reason is that clinical trials have inclusion and exclusion criteria that may not match the real population going to to the doctor, so if there is something showing up in the gen pop, docs want to know. The other reason is that rare events may not have been picked up even in the largest clinical trial will be picked up once the treatment is used in a large population.

One of the best examples of this latter phenomenon is Trovan. I have seen the estimated complication rate for Trovan to be as low as 1 in a million, yet it was nearly withdrawn in the US, and is severely restricted to patients who are going to die and have exhausted every other option. If we were to apply this standard to chiropractic neck treatments, given the severe adverse event rates of death and stroke, the eligible population would be about 50 people.

700 spontaneously reported events is a huge number, especially when the docs doing the writing up did not administer the treatment (one subtext to a lot of these case studies is a warning - do not screw up like we did). And as Natalie pointed out, not everyone bothers to write up an article in a journal for every event they see - Natalie were those events you saw published?

My best estimate is that you would see about 700 cases of liver or renal damage in the literature for Tylenol, and guess what? The FDA just slapped them with a black box warning.

Steve Buchheit said...

Janiece, I'm not making medical claims, I'm merely pointing out that the article is using bad statistics (raw numbers without context, ie. 700 out of 1,000, 10,000 or 100,000; or explanation of highly variable terms such as "adverse" which can sound terrible but might mean the "soreness" he discussed earlier). So asking for double blind test to support my contention is a non sequitur. As for a double blind test to the efficacy of chiropractic practices, I'll instead point back to the article you quoted where the author admits that it can help with certain conditions and has just as high a success rate as other "accepted" modalities and practices (since we're discussing the article and it's content, I believe you'll find this is a valid argument).

My comments, other than the anecdote of my experience with chiropractors, are about the article you reposted, which is not much more than an opinion piece for promotion of their book (a non peer-reviewed organ).

"The point here is not that drug therapy per se is the end-all or be-all of medical research." That wasn't my point at all, and you're making excuses. My point was he discredits one therapy for an outrageous claim when it can be shown that other therapies also make a similar claim and also can not deliver.

The line in question is "This organisation is the respectable face of the chiropractic profession and yet it happily promotes bogus treatments." If he had limited his comment to the treatments he lists in the sentence before that, he would be on solid ground. However, that sentence is a general criticism of the BCA and is a comment on all treatments they promote (which he admits can be effective for some conditions, which undercuts his statement).

So, from saying chiropractic doesn't help with certain conditions he is making a statement about the whole practice being "bogus" which is not supported by his data in the article. And yes, the BCA didn't attack his claims in the article, but his general claim that the whole of chiropractic is "bogus." Has the reprinted article with the redactions been challenged? Not that I can see. So the claims of "silencing critics" is also made "bogus." If the BCA had attacked the reprinted article, or attacked his research, I'd agree with the statement of suppression. So the "we must get the word out" (reprint everywhere) becomes a defacto attack on the chiropractic profession (the other line redacted, "And even the more moderate chiropractors have ideas above their station" is also worrying and sounds more like the general, "Don't claim to be 'real' doctors").

For someone being a "skeptic" I expect a better examination of their own side of the argument.

Steve Buchheit said...

Nuerondoc and John the Scientist, please don't make me reiterate the history of the rise of the AMA and the foundation of what we now call "traditional" medicine and the political fights surrounding it.

Nuerondoc, you've seen two cases of stroke related to chiropractic treatment (my guess is it's probably higher). How many adverse cases have you seen from drug interactions or failure of the accepted drug therapy to work? How many cases have you seen of strokes cause by blood clots as a result of surgery? Is there a possibility those two cases are magnified in your perception by your personal biases?

John the Scientist, my wife holds a PhD in Ethnobotany (Masters in Genetics). I have seen the FDA drug trials, also with a mathematics background I can see the sadistic statistics within the system (when a "statistically significant" benefit can mean 50% effective, but mean a <2% change in the overall population of the study). Of course the methods are "accepted" and therefore "standard."

If the 700 cases in the medical literature (which may also include studies IIRC) were from one treatment, that would be worrying. However that statement is akin to say there were 700 cases of adverse events in the literature because of surgery (not a type of surgery, just any surgical procedure and any adverse effect such as infection of the incision cite). And it would also be worrying if it was 700 case in the literature over the period of one year. Again, there's no context of the figure given.

And I'll agree that the 50% mild adverse effect after all treatments is worrying. That's their best argument.

Steve Buchheit said...

And I should reiterate here, I'm a person that uses "alternative" methods for the purposes they help with. With chiropractic I've used them to help with muscle and joint pain (lower and upper back, jaw, foot pain form fallen arches, and for therapy to help correct Tenosynovitis). I wouldn't go to one for the therapies the article listed (because I already knew they wouldn't work), just like I wouldn't go to a surgeon to help with a cold.

When I had a kidney stone (without knowing what it was), I didn't go to my chiropractor or any other modality. I went to the emergency room. When I need surgery I see a surgeon who specializes in what I need. When my regular physician says "take metformin to help with your insulin resistance, that'll help you lose weight which will help your insulin work better" I take the metformin.

Also, I agree that any modality that says, "We can treat everything wrong with you" is blowing smoke. Only death treats everything.

Wendy said...

I'm with Jim...now where did we put that clue by 4??

Like every other profession, there are good Chiros & bad ones. As a law firm that does personal injury work, we find that many times treatment by chiropractic methods, although perfectly valid, approriate and successful for the injuries in question, is viewed in a lesser light than conventional physical therapy supervised by a MD's office.

We're also less likely to get verdicts in our client's favor should the case go to trial if chiropractic services were used.

Which is too bad because we know several MD types that regulary work with and send patients to chiropractors and vise versa, depending on the needs of the patient.

WendyB_09

Now I better get to work before the attorney in question finds be discoursing with you guys!!

Janiece Murphy said...

Steve, I actually am familiar with both sides of this argument, although my desire to go to bed last night rather than write a dissertation on the subject may make the case appear otherwise. If you want information on the "skeptical" side of the argument, I will recommend the link Natalie provided from Dr. Novella. I choose not to reiterate it here, partly because Dr. Novella already did a fine job, but mostly because I think the "my sister is a rocket scientist" argument damages credibility, as it did when you used it with Natalie and John.

Again, from my perspective, the issue here is efficacy in general and acceptable risk to efficacy specifically. Please note that may not be the issue from Simon Singh's perspective - I can't speak for him, but those are the reasons I chose to republish the article. Mr. Singh is arguably more stabby about this than I am, and is not without his own agenda. But his agenda is not my agenda - I don't own his book, don't intend to buy it, and feel no obligation to "make excuses" as you say. Please realize that the issue on the lawsuit was the use of the word "bogus." The BCA claimed that the use of the word implied that Mr. Singh was accusing them of knowingly advocating ineffective treatments. Mr. Singh claims that chiropractic actually believes their own hype, and even though the treatment doesn't work, chiropractors actually believe that it does. Semantics, to be sure, but there you go. My own opinion is that chiropractors actually do believe they're helping.

Chiropractic makes a LOT of claims. Claims you yourself have admitted are "bogus." So my issue is two-fold:

1. Chiropractic makes "bogus" claims about colic, asthma, etc. This is about quality control in modern health care. There is no evidence whatsoever that chiropractic can resolve most of the issues it claims to resolve. So why are they allowed to make them? It's false advertising at least, and malpractice at worst. The efficacy of science-based medicine may also be suspect, but I do know that science-based medicine is required to show that a treatment actually, you know, works before it can make it past the FDA. Not so much with Chiropractic.

2. Even in cases where there might be some benefit (i.e., back pain), the risk to efficacy is higher than it is for science based treatments. I want the same standard applied to both, not science based standards applied to M.D.'s and "we think it's safe and it works, so it does" standards applied to chiropractors.

I do agree that the dissemination of the article is an attack on chiropractic. And I'm okay with that, because (in my opinion) chiropractic does more harm than good, and shouldn't be allowed to make outrageous claims with no evidence to back them up. So I chose to republish the redacted article, rather than the entire article (as Orac did).

As for adults who choose to use alternative methods, I have to say I really don't care. As long as the practitioners aren't making false claims or exposing their patients to excessive risk, then it's no skin off my nose.

Steve Buchheit said...

Janiece, I agree that they shouldn't be able to make claims that research has proven aren't substantiated. Again, his claim of "bogus" was on the entire practice (and organization), not just on the diseases he cited. In that case, I believe the court was correct in saying he libeled the BCA. If he had limited his "bogus" comment to the treatments he discussed, I would feel the opposite (even if he would have gone as far as "We've shown these claims to be bogus and that calls into question all their other claims" he would have been on solid ground).

I would also say, Chiropractic can't claim all of what it says it can cure, but to move that to "most" only works in the context of saying "Chiropractic can cure everything."

As to the side effects of the treatments of Chiropractic, I could point out that since Chiropractors don't prescribe drugs, claiming "discomfort from pain" after treatment isn't qualified as more or less pain than from the original disease the patient went in for treatment for, neither does it qualify for long term benefit (such as there is some pain left as the patient leaves, but then that pain goes away and the symptoms don't return or at least don't return as fast as say stopping pain medication or muscle relaxers). As an example, when I leave a dentist from having my wisdom tooth extracted I am in more pain than when I entered, I have a greater discomfort from the treatment than from the disease (at that moment, getting the tooth extracted was to prevent even greater discomfort and pain later). However that pain and discomfort is masked by the pain killer prescribed and goes away quickly and I've avoided the greater pain of if I had let the tooth become impacted.

I could also make the same argument about chemo-therapy. After chemo patients are more tired, sore and in more pain than they arrive (typically). Should we discontinue chemo because of that? Surely not as the long term benefit outweighs and out lasts the alternatives.

I hope you can see I'm agreeing with the points you are making. I am disagreeing with the extrapolation and jumps to throwing the baby out with the bathwater. Also I'm making the argument that some of his claims also aren't being evaluated on the same playing field or being made in context. They are being made to ridicule (and, "oh, BTW, don't you want to buy my book to learn more about it" of which the "repost everywhere" is an example of viral marketing - see examples of marketers trying to get people to blog about their products).

In general I'll just remind everybody that when I was growing up there was the standard line about how taking dietary supplements or herbals were considered just as outside the mainstream of medicine. At the very least it was considered "harmless and silly" because they didn't do anything (at worst because it kept people from seeking treatment that could help). Now we know vitamin therapy and nutritionists are a part of "science-based" medicine (aka that which is supported by the AMA, which has it's own axe to grind and market to protect). Herbals have proven effective in some cases (obviously not in all the whackjob extreme claims) and are now considered "dangerous" because they can interact with and/or disable prescription drugs (which is true), are highly effective on the body and can be deadly when used improperly (Ephedrine).

And yes I did read the article neurondoc linked to last night before I commented.

Steve Buchheit said...

that is "read it before I commented this morning."

Janiece Murphy said...

Steve, fair enough.

I will say that one of the reasons I'm a fan-girl of science is its ability to change and grow as new data becomes available. I am completely willing to change my mind about something provided that demonstrable, repeatable evidence is available showing that my original opinion was full of shit. So far, chiropractic (along with homeopathy and a bunch of other woo) lacks compelling evidence to support it, so I call shenanigans.

Steve Buchheit said...

Janiece, I'm also a fan boy of science. Which is why when I see the argument of "You claim A, B and C. I've disproved A, so B and C are also wrong" (without B and C dependent on A) gets me going.

MWT said...

Heh, I saw Neurondoc's post first and made my comment there. But it looks like the expanded, detailed version is already going on here. ;)

MWT said...

Also, nobody is challenging Neurondoc's two anecdotes about what she saw? :p

Steve Buchheit said...

MWT, as the resident crank of this thread, I see absolutely no reason to question neurondoc's credibility or memory of the issue.

MWT said...

I meant it in the sense of anecdotes vs. data. Your anecdotes get taken to task for being anecdotes, while hers get to pass. I see a bias. :p