Beware the spinal trap

Simon Singh
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[BPSDB] Along with many other blogs and magazines, I am reproducing, below, Simon Singh’s article on chiropractic, which led to his being sued for libel by the British Chiropractic Association. The full story can be found here. The point of the publication is to show support for Singh in his fighting the libel case. Please sign the statement at Sense About Science, if you haven’t already done so.

It is true, as Singh writes below, that chiropractors make claims for treatments for which there is little or no evidence of their effectiveness, but there are definite risks associated with chiropractic.

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.

Update: The above article was modified by removing the words complained of by the BCA. However, the BCA has published these words itself , so you can form your own opinion on whether the original article could damage the reputation of the BCA or not.

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Analysing the chiropractors’ statements

[BPSDB]There seems not to have been much comment on the press statement by the British Chiropractic Association on 7 May about the libel case against Simon Singh. This appears to be highly misleading. It reads in part:

In April 2008 Simon Singh published an article in the Guardian newspaper and on Guardian Online in the course of which he wrote that:

“the British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence. This organisation is the respectable face of the chiropractic profession and yet it happily promotes bogus treatments.”

The BCA asked Dr Singh to retract his allegations because they are factually wrong, defamatory and damaging to the BCA’s reputation. Dr Singh refused to do so.

In July 2008, the BCA issued libel proceedings against Dr Singh. He defended his position and the case has been continuing.

At a hearing on 7 May 2009 in the Royal Courts of Justice before Mr Justice Eady, Dr Singh’s submissions that what he published was not defamatory and that it was fair comment were roundly rejected by the Judge. Mr Justice Eady held:

1. that what Dr Singh had published was defamatory of the BCA in exactly the way the BCA had claimed; and

2. that Dr Singh’s allegations were not comment but were serious defamatory allegations of fact against the BCA.

Dr Singh’s application for permission to appeal to the Court of Appeal was refused by the Judge. Dr Singh has indicated, however, that he proposes to challenge that decision at the Court of Appeal and he now has three weeks to lodge that challenge.

Mr Justice Eady ordered Dr Singh to pay the BCA’s costs of the hearing within 28 days.

After the hearing BCA President Dr Tony Metcalfe said, “The BCA brought this claim to preserve its integrity and reputation. I’m delighted that the Judge has vindicated the BCA’s position.”

The trial will conclude later this year.

In actual fact, the trial has not taken place, so the BCA has not been in the slightest degree “vindicated”. All the judge has done is issued a perverse ruling on the meaning to be placed on Dr Singh’s words, so that in order to win the case he has to prove something that he apparently did not mean in the first place. It also means that the case no longer has any bearing on the real scientific issue, which is whether the evidence that these treatments are effective exists.

However, the BCA seems to have quietly and implicitly conceded that what Dr Singh wrote is true, as they have removed the offending document (checked on 19 May 2009), with the claims that Dr Singh complained of,  from their web site. It remains true so far that the BCA has not produced “a jot of evidence” for this claim, and from the fact that they went to law rather than produce the evidence leads me to conclude that the evidence does not exist. I think it is also a reasonable inference that if the BCA makes the claims in future without producing the evidence, then it is doing so in the knowledge that the evidence does not exist.

I have looked through the publicly-accessible part of the BCA web site, to the greatest extent I could, and it does not appear to repeat the claims elsewhere. As regards children, the material on the web site consists of claims so vague that they would be difficult to challenge (as in a video on pregnancy and children), general good advice on posture and activity, and scare statistics on back pain. In fact, if you looked through those specific materials, you would find it difficult, if not impossible, to know exactly what a chiropractor does, except that they claim to have some sort of knowledge of the causes of back pain.

As it’s hidden behind a log-in, I have no way of knowing what information the BCA has passed on to its members. If it has told them the same as in the press statement, then it is misleading its members. It should at least make it clear to them that it cannot support the claim that it originally made about treating childhood ailments.

I have been looking at a few chiropractors, selected because they are local to me. One of them makes very serious claims on her web site about the effectiveness of chiropractic in the treatment of specific conditions, including some referred to by Dr Singh. I have contacted the practice, and am waiting for someone to get back to me. Otherwise, the general impression that I get of the public front of chiropractic is vagueness. I hope to post more on this later.

A Carnival of B**** Chiropractic

[BPSDB]At the Quackometer, Andy Lewis is organising a Carnival of B**** Chiropractic (insert your own B-word there). This is an opportunity, I think, not only to do some serious investigation and make some serious points about the validity of chiropractic and the claims that are made for it, but  also to make fun of the absurd English libel law. Please visit the Quackometer.

Simon Singh and the back quacks

[BPSDB]I’d like to support Simon Singh in his current legal difficulties but I have no intention to join Facebook. (I did start signing up once but I read the terms and conditions and changed my mind.)

If there are some who don’t know what this is about, Dr Singh is a victim of the broken libel laws of England. He wrote an article criticising chiropractors for the following claim by the Brtish Chiropractic Association (BCA): “There is evidence to show that chiropractic care has helped children with the following symptoms: Asthma Colic, Prolonged crying, Sleep and feeding problems, Breathing difficulties, Hyperactivity, Bedwetting, Frequent infections, especially in the ears”.  Dr Singh and his colleague Edzard Ernst studied the evidence thoroughly and found none that supported the claim.

However, the BCA did not withdraw the claim (although the original leaflet is no longer on the BCA website) and did not produce any evidence for the claim. Instead, it sued Dr Singh for libel.

The BCA has put out a highly misleading statement. The BCA has not been “vindicated” as the trial has not yet taken place (and may yet not happen). It is important to remember that damages in a libel case are awarded as compensation for loss of reputation. The BCA has not been awarded damages, only costs of the hearings so far.

What has happened is that the judge has put an obstacle in Dr Singh’s way by insisting that, to win his case, he must prove something that he didn’t mean in the first place (and apparently, even the BCA did not claim that he meant it). He has to prove that the BCA dishonestly promotes unproven treatments. Jack of Kent has further details from a lawyer’s point of view.

The English libel law is a litigant’s delight, but reputation is not only a matter of the law. It is likely that the BCA will come to regret its actions. The fact is that they made the claims about chiropractic (even though they have taken the document off their web site) and they have failed to provide any evidence to support them, opting for legal action instead. Suppose that the BCA  had come forward with evidence. I am sure that Dr Singh would have withdrawn his criticism graciously, and if he had not, there might then have been grounds for a libel action.

As it is, going straight to law (or threats of legal action) without first publicly answering criticism may well become widely thought of as a distinguishing mark of the quack, especially when the matter is one of scientific evidence. See Quackometer and the Society of HomeopathsDavid Colquoun and Ann Walker, and Ben Goldacre and Matthias Rath – if you follow these issues through, you will see that the quacks lost in each matter. A legal ruling can offer only a monetary remedy, but trying to suppress criticism sets in process a whole series of consequences which may never have been intended.

And as far as I’m concerned, the BCA has demonstrated its lack of integrity, and also why you should never touch a chiropractor with a bargepole – or, rather, never let them touch you.