Jul 29 2009

Beware the Spinal Trap

Last year Simon Singh wrote a piece for the Guardian that was critical of the modern practice of chiropractic. The core of his complaint was that chiropractors provide services and make claims that are not adequately backed by evidence – they are not evidence-based practitioners. In response to his criticism the British Chiropractic Association (BCA) sued Simon personally for libel. They refused offers to publish a rebuttal to his criticism, or to provide the evidence Simon said was lacking. After they were further criticized for this, the BCA eventually produced an anemic list of studies purported to support the questionable treatments, but really just demonstrating the truth of Simon’s criticism (as I discuss at length here).

In England suing for libel is an effective strategy for silencing critics. The burden of proof is on the one accused (guilty until proven innnocent) and the costs are ruinous. Simon has persisted, however, at great personal expense.

This is an issue of vital importance to science-based medicine. A very necessary feature of science is public debate and criticism – absolute transparency.This is also not an isolated incident. Some in the alternative medicine community are attempting to assert that criticism is unprofessional, and they have used accusations of both unprofessionalism and libel as a method of silencing criticism of their claims and practices. This has happened to David Colquhoun and Ben Goldacre, and others less prominent but who have communicated to me directly attempts at silencing their criticism.

This behavior is intolerable and is itself unprofessional, an assault on academic freedom and free speech, and anathema to science as science is dependent upon open and vigorous critical debate.

What those who will attempt to silence their critics through this type of bullying must understand is that such attempts will only result in the magnification of the criticism by several orders of magnitude. That is why we are reproducing Simon Singh’s original article (with a couple of minor alterations) on this site and many others. Enjoy.

—–

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.

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35 responses so far

35 Responses to “Beware the Spinal Trap”

  1. Feboon 29 Jul 2009 at 12:45 pm

    There’s something I do not understand. In the article, singh writes:

    “You might think that modern chiropractors restrict themselves to treating back problems, but in fact they still possess some quite wacky ideas. The fundamentalists argue that they can cure anything. And even the more moderate chiropractors have ideas above their station. 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.”

    Which seems to be pretty clearly and strongly implying that the British Chiropractic Association was being consciously dishonest in promoting chiropractic for treating the children’s ailments in question.

    Yet Singh insists that that is not what he meant, and that by forcing him to defend that position is forcing him to defend something he never meant in the first place (according the his wikipedia article).

    Is there something that I missing here? Why is he trying to say he didn’t mean what he said, instead of defending the truth as he originally presented in the article?

    Why didn’t he just argue, “Yes, it seems given the evidence that the BCA is consciously promoting dangerous uses of chiropractic; I would be happy to respond to their refutation of that evidence!” Wouldn’t any reasonable judge throw the BCA’s libel claim out of court without giving it a second thought if Singh just admitted that he meant what he said, and that what he said was correct?

  2. Steven Novellaon 29 Jul 2009 at 12:55 pm

    Febo – it would be almost impossible for Singh to prove what was in the mind of the BCA and its members. He would have to prove that they knew what they were promoting was wrong.

    And also – he did not intend that at all, and elsewhere clearly states that chiropractors generally believe the nonsense they promote. How can they be “deluded” and committing conscious fraud at the same time?

    In reality, though, its more complex still. Practitioners of “bogus” therapies may be deluded by anecdote and weak evidence, and know that there is no solid evidence, but then rationalize away the lack of hard evidence, explain away the negative evidence, and focus on the poor evidence they have, because they “know” it works from their own experience. So teasing out different beliefs would be impossible – and Singh has the burden of proof.

  3. Feboon 29 Jul 2009 at 1:15 pm

    Why does Singh have to prove what what in the mind of the BCA and its members? Isn’t it reasonable to assume that a profession organization like the BCA would have access to the scientific literature on the subject, so couldn’t he use the scientific literature to support a “fair comment” defense?

    Also — why are these cases so expensive? Why couldn’t he just show up in court without a lawyer and tell truth?

  4. Steven Novellaon 29 Jul 2009 at 4:18 pm

    You need to be familiar with the English libel system. It costs 130 times the average cost of defending a libel case in Europe. This is not all lawyer’s fees, and it is highly debatable whether it is advisable to navigate the libel courts without representation and trust to just telling the truth. This is about meaning and perception – not facts.

    The way the judge interpreted Singh’s statement he would have to prove that the BCA knew and believed that what they were doing was “bogus” – not legitimate. He wants to defend the point that the treatments are in fact not evidence-based. That distinction was the essence of the judge’s initial decision.

  5. Jim Shaveron 29 Jul 2009 at 4:47 pm

    Steve:

    You obviously edited out Singh’s controversial statement that referred to chiropractic treatments as “bogus”. I support Mr. Singh and have signed a petition stating so, and I also appreciate your work on his behalf specifically and against pseudoscientific medicine in general. What I’m wondering is this: What was your purpose in editing Singh’s original article? Are you concerned about your own vulnerability to these idiotic and draconian English libel laws, or does removing the “offending” statements in some way avoid more jeopardy for Mr. Singh?

    I am wondering about this from a practical perspective.

  6. Feboon 29 Jul 2009 at 5:08 pm

    I feel kind of funny asking all these challenging questions, since I completely agree with Singh’s position of chiropractic and do not think that he is guilty of any sort of Libel, but this situation seems like it is being blown out of proportion for the sake of publicity.

    What are the costs that figure into the “130 time the cost of average cost of defend a libel case in Europe” claim?

    Are judges and courts really so ignorant and irrational that they cannot simple read Singh’s article and throw the libel claim out of court? If not, why not? I mean specifically — not just these vague “the libel laws are terrible” statements — what exactly is terrible about them?

  7. PPon 29 Jul 2009 at 6:24 pm

    Febo, check this link for a comparative study of costs:
    http://www.senseaboutscience.org.uk/index.php/site/project/342

    That site also has more information in Simon Singh’s case:
    http://www.senseaboutscience.org.uk/index.php/site/project/333

    I think it’s a pity Dr Novella posted the lawyerized version of the article instead of the original one. What’s the point of reposting the article if the phrase the whole lawsuit is about has been removed?

  8. Steven Novellaon 29 Jul 2009 at 8:35 pm

    Jim – I did not edit the article. Simon’s lawyers did. This is the version they sent out to be reposted. In fact, I asked them to allow me to repost the unedited article, but they declined.

  9. Steven Novellaon 29 Jul 2009 at 8:37 pm

    Here is the removed paragraph:

    “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.”

  10. HHCon 29 Jul 2009 at 10:25 pm

    The bogus treatments which Singh refers to may involve BCA’s treatment for vertebral subluxation. They could be working with C2 for ear infections, T1 for asthma, C5 for crying, L2 for colic, C1 for sleeping, and C4/T6 for feeding problems.

  11. HHCon 29 Jul 2009 at 10:37 pm

    Palmer’s original treatments for deafness most likely worked with C2/C3 and for the heart condition, treatment with respect to T2.

    I will report a problem with the Gonstead techniques. I received a rapid right to left sided torque which impacted my ability to stand from the seated position at about L4.

  12. HHCon 30 Jul 2009 at 1:00 pm

    When working in Britain, the BCA spokesman prefers the usage of the words, partial dislocation instead of subluxation.

  13. Feboon 31 Jul 2009 at 4:05 am

    Thanks PP, for the link to so actually data. Not the Sense About Science site, which basically just repeats the same vague statements that we hear everywhere, but the link under the pretty chart that leads to the Oxford Study on CFA. Unfortunately, that study only deals with the problems of the costs associated with CFA, and doesn’t help answer the rather obvious questions I still have regarding Singhs case.

    1) Why could he not have simply printed a clarification in the next issue of The Guardian, pointing out that he did not mean to imply that he necessarily knows what the members of the BCA is thinking, that they might just be ignorant?

    2) If he is intentionally dragging out this case for publicity (I understand that these laws need to challenged) why not just admit it? Scopes admitted fromthe start that his case was intentional.

  14. PPon 31 Jul 2009 at 5:18 pm

    @Febo,
    I’m not a lawyer and it’s been a while since I dug into this case, but I believe this is due to the peculiar nature of British libel laws.

    From what I’ve understood is that in British libel cases:
    a) the defendant has to prove that his statement is true (as opposed to the claimant proving the statement is false)
    and
    b) the judge decides which standard of evidence the defendant has to meet to prove his statement true.

    A public clarification from Simon Singh (as you suggest he should’ve done) wouldn’t change anything as the judge gets to decide what needs to be proven. In this particular case the judge has ruled that ‘bogus’ means (something like) deliberate deception and that Simon Singh thus must prove that the BCA deliberately deceived people. That is not what he meant, probably not what the BCA did, and it is in any case impossible to prove.

    If I’m not mistaken it is this ruling (defining the word ‘bogus’) which Simon Singh is appealing currently. The actual libel case is yet to start.

  15. Feboon 01 Aug 2009 at 5:33 am

    Thank you for that explanation, PP. I also got that explanation from going back and listening to the SGU interview with Singh — which I probably should have done in the first place.

  16. Feboon 01 Aug 2009 at 5:35 am

    But now the question is, why are they releasing an edited version of the article? Isn’t that tantamount to admitting that there was something wrong with the original article?

  17. Joeon 01 Aug 2009 at 8:40 am

    On Thursday, July 30, the appeals court declined to hear Singh’s appeal of the lower court judge’s bogus definition of “bogus.”. No more information was released. When he gets the court’s letter (and there is a postal strike) he may be have one more venue for appeal in the UK. There is also a European court to which he can appeal.

  18. Joeon 01 Aug 2009 at 9:00 am

    @HHC on 29 Jul 2009 at 10:37 pm “Palmer’s original treatments for deafness most likely worked with C2/C3 and for the heart condition, treatment with respect to T2.”

    That is nonsense: the claimed results have never been replicated.

    @HHC on 30 Jul 2009 at 1:00 pm “When working in Britain, the BCA spokesman prefers the usage of the words, partial dislocation instead of subluxation.”

    More nonsense- it doesn’t matter what you call it if it is fictitious; which it is.

    You should go to http://www.quackwatch.org and its subsidiary http://www.chirobase.org to learn more. Chiros have never been able to provide physical evidence for subluxations, although they used to pretend they could see them on xrays. That was debunked when chiros were asked, individually, to point to the subs on unmarked xrays and their responses were random. Similarly, investigators going for one chiro consultation after another were told they had subluxations; yet they were different with each different chiro.

  19. HHCon 01 Aug 2009 at 5:02 pm

    Joe, To which court in England are you referring with respect to the July 30th decision, the House of Lords appeals court?

    With respect to Palmer’s work, we can’t “replicate it”. All patients which he worked with are deceased. We can only make an educated guess about whether his patients improved from baseline, for example, a patient started to ear some sound in one or both ears, or a patient may report being more comfortable given the treatment for the claimed heart condition. I have been told by chiropractors who come from the Davenport school that Palmer was the P.T. Barnum of the business. He spent his money for purchasing circus animals and equipment. He loved feeding his alligators.

    The BCA has its own jargon which they currently define and use. In the USA, “subluxation” can refer to a restriction of movement. There are biomechanical issues related to physical movement problems. For example, a joint may not move properly impacting other joints, disks, and muscles. Biophysics is the direction of the future in chiropractic care.

  20. Joeon 01 Aug 2009 at 8:38 pm

    @HHC on 01 Aug 2009 at 5:02 pm “With respect to Palmer’s work, we can’t “replicate it”. … We can only make an educated guess …”

    No, chiros make uneducated guesses. Educated people realize it is all nonsense- that is, not accurately reported.

    @HHC No “biophysics” is just sciencey jargon for the idiots that are chiropractors.

    There is no ‘chiropractic’ subluxation by any name or description. Try this from the American chiros themselves http://www.chirocolleges.org/paradigm_scope.html Then, go study the sites (quackwatch and chirobase) to which I referred you, earlier. Ala Dr. Harriet Hall: there is more evidence for the Tooth Fairy (I got a nickel under my pillow for each baby tooth I lost) than there is for the “subluxation.”

    Get with the real program- chiropractic is bogus; it is a cult of ignorance.

  21. Feboon 02 Aug 2009 at 4:36 am

    @ HHCon 01 Aug 2009 at 5:02 pm: “With respect to Palmer’s work, we can’t “replicate it”. All patients which he worked with are deceased.”

    To “replicate” work in the scientific context does not require the original subjects, rather the reverse — it demands that comparable results be demonstrated independently, by different researchers. Anecdotes about what patients might point to interesting areas for investigation, but they are worthless as data. Although in the case of most chiropractic claims, they are worthless as indicators of areas for investigation as well, since pretty much every chiropractic claim has been thorough tested and shown to be bogus — which makes one wonder why pointing out that BCA “happily promotes bogus claims” can be considered libel, since it is a completely true statement, even if you accept the interpretation forced upon it during the pretrial hearing.

  22. HHCon 02 Aug 2009 at 3:30 pm

    Disc herniation can be visible on x-rays. So in BCA’s terms, perhaps partial dislocation refers to partial herniation of a disK. For example, I had an internist, M.D., a sports physician who also worked with the Chicago Bears. He would diagnose disK herniation through physical examination, even if it didn’t show on
    x-rays. Chiropractors trained in orthoepaedic chiropractic carehave unique skills. They are required to pass medical boards for their speciaity. :-*

  23. Joeon 03 Aug 2009 at 6:31 am

    HHC,

    Go to http://www.quackwatch.org and learn about the nonsense you are spouting. Chiropractors are masseurs with delusions of grandeur. if you have a herniated disk, they can do nothing more than massage it.

    Yes, chiros take exams; but they are meaningless since they are graded by chiros- so everyone passes. Those added diplomas only enhance their credibility for the gulllible.

  24. HHCon 03 Aug 2009 at 2:11 pm

    Joe, I agree some chiropractors have illusions, but so do all professionals who work in healthcare. They believe they are going to make a middle class living or better. Those that have delusions are most likely doing drugs.

  25. Joeon 03 Aug 2009 at 9:33 pm

    @HHC,

    You continue uninformed, at this point, it must be intentional.

    Chiropractic, faith healing, homeopathy, crystal healing, bleeding, horrific purgatives etc. are totally based in ignorance. Incompetence is standard practice for chiro, not the exception.

  26. SteveAon 04 Aug 2009 at 7:19 am

    I’m coming to this a bit late but I have to object to the following:

    “In England suing for libel is an effective strategy for silencing critics. The burden of proof is on the one accused (guilty until proven innnocent) and the costs are ruinous. Simon has persisted, however, at great personal expense.”

    If I’m carrying on a business and someone publishes an article saying I’m up to no good, then I’M the injured party, I’M the person who is innocent untill proven guilty. It’s up to my accuser to prove their case.

    Having said that I’m confident that Simon will expose the BCA for the bunch* of quacks they are.

    *What’s a better collective noun for quacks? A fraud? A conspiracy?

  27. Joeon 04 Aug 2009 at 12:33 pm

    @SteveA on 04 Aug 2009 at 7:19 am “If I’m carrying on a business and someone publishes an article saying I’m up to no good, then I’M the injured party, I’M the person who is innocent untill proven guilty.”

    I beg to differ. When you assert anything (e.g., libel) you must prove your claim.

    In this particular case, the question is not whether chiros are quacks. The judge has ruled that when Singh called their treatments “bogus” that meant “deliberately fraudulent.” Which means, a proper defense requires him to show that they know the treatments don’t work (what is on their minds); whereas, we think they believe their bogus claims because they are deluded.

  28. HHCon 05 Aug 2009 at 12:58 am

    If neurology got past phrenology, then chiropractic care can move beyond subluxation. Know that the British judge in the Singh case is more knowledgable on the subject matter than those making comments on this blog.

  29. Joeon 05 Aug 2009 at 8:08 am

    @HHC on 05 Aug 2009 at 12:58 am “… the British judge in the Singh case is more knowledgable on the subject matter …”

    It depends on what you mean by “subject matter.” If you mean UK libel law, sure; but he has previously made decisions that shocked the legal community there, to the extent that he has been remonstrated by higher courts. Does he know more about the meaning of “bogus,” perhaps; I would like the opinion of lexicographers. The judge certainly is not better informed on the subject of chiro than I, and many others here.

    If Singh loses the case, it will be based on the judge’s definition of “bogus” not the legitimacy of chiro for treatment of the conditions (colic, asthma, etc.) cited in Singh’s article. When the BCA laterly published their data “supporting” such treatment claims, it was a joke, see here http://www.sciencebasedmedicine.org/?p=555 and here http://layscience.net/node/598 among many deconstructions.

    You can read legal commentary on the case here http://jackofkent.blogspot.com/

  30. Joeon 05 Aug 2009 at 8:42 am

    @HHC on 05 Aug 2009 at 12:58 am “If neurology got past phrenology, then chiropractic care can move beyond subluxation.”

    Did neurology develop from phrenology? Nevertheless, chiropractors have had ample time to adopt legitimate practice, as osteopaths have done (only in the USA). All the information they need is available, free, in libraries. Chiros clearly don’t want to become legitimate practitioners because they will lose too much business, or they will have to spend a lot of money to make their schools into something professional, and competitive, such as PT. Chiropractors who do try to reform are reviled by the rest.

    Suppose chiros domanage to move beyond their fairy-tales. Can you explain to me why chiros should be allowed to continue to ply their bogus trade as if it were legitimate until it becomes so?

  31. HHCon 05 Aug 2009 at 4:25 pm

    The practice is legitimate in Great Britain and the U.S.A.! Why do they keep fairy tales around? Because people love fairy stories and myths. What would we do without Palmer’s circuses? Would we prefer to be entertained by information about partially herniated disks or the autonomic or parasympathetic systems? The average person with lower back pain wants a quick fix, not a lecture in anatomy. So, its up to the professionals to keep revising their definitions to fit the knowledge and science of the times. And if you hear a lecture by a Dr. Quack, just pull on his tail feathers a bit and he’ll straighten up.

  32. SteveAon 06 Aug 2009 at 7:50 am

    # Joeon 04 Aug 2009 at 12:33 pm “I beg to differ. When you assert anything (e.g., libel) you must prove your claim. ”

    How does this differ from what I said?

    If I accuse a cat-food manufacturer of mixing rat meat with their tuna, and the manufacturer accuses me of libel, then it’s up to me to prove my claim, it’s not the manufacturer’s job to run around and try to prove me wrong. This arrangment is practical, fair and just.

    My objection to Steve’s original post was that he seems to think this arrangement is somehow ‘cockeyed’ and that the opposite ought to be true, ie that the manufacturer should be the one trying to prove themselves innocent of wrongdoing in the face of any claim anyone might want to make about them.

    As to the ‘quacks’ comment. I didn’t say that the case had anything to do with the BCA being ‘quacks’, I just used the term to describe them.

  33. HHCon 06 Aug 2009 at 11:21 am

    SteveA, I concur with your objection about the original post.

  34. Joeon 18 Oct 2009 at 2:58 pm

    I hope this is not considered excessive, I am not certain of the overlap in blog readership:

    A quick recap- Simon Singh wrote an Op-Ed piece saying the British Chiro Ass’n (BCA) saying they offered “bogus” treatments* and the BCA sued him for libel. The judge (Eady) in the case found Singh’s comments were meant as fact, not opinion, and that “bogus” meant fraudulent (as-in, chiros know their methods don’t work).

    He was “barred” from appealing Eady’s findings. Except, under British law, he could ask the higher court for permission to appeal.

    Last Wednesday (Oct. 14) the appeals court granted Singh permission to appeal Eady’s findings.

    Then, the spit hit the fan and we await the repercussions. The BCA posted a press-release saying that Singh had written a malicious attack on them. According to a lawyer involved peripherally with the case, the BCA has libeled Singh by saying he was “malicious” and now Singh can counter-sue. http://jackofkent.blogspot.com/2009/10/bca-defame-simon-singh.html In fact, the judge on Wednesday noted that malice was not involved. The BCA quickly changed the wording in the PR statement; but they were too late make it like it never happened.

    The lawyer has noted that it is up to Singh to decide how to proceed; but it gives him a good option.

    * Singh mentioned specific, bogus treatments (for colic, ear infections, etc.), not everything they do.

  35. HHCon 18 Oct 2009 at 10:46 pm

    If BCA posted a release that Singh had written a malicious attack, then they meant that he wrote with ill will and without cause.

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