Getting Spammed By Mabus

I’m told that getting Twitter-spammed by the troll Mabus is recognition that I’ve annoyed somebody by commenting about alternative medicine. Is it sad that I feel proud? I ignored him and intend to continue to do so.

It happened in the process of a discussion on Twitter with a chiropractor, @Liam_Mulvany – who I am sure is sincere, for what that’s worth – about the use and value of his chosen ‘therapy’. One thing I commented on during the discussion was that his website testimonials only mentioned back pain and asking if he treated other conditions with chiropractic; he said that he did not. (“I only deal with musculo skeletal probs.” was his tweet, to be exact.) This has resulted in him commenting on an obscure page on my blog. I’ve no problem with that – I’m here to engage, although I expected it to be more with teachers than chiropractors. I’ve replied to it, here. I did however feel that as I’d spent a little while checking my references and laying out my reasoning, just like I tell my kids to do at work, I should put it up as a blog post too.

So here it is.

His comment:

I like this.

We examine a situation(somebody with back pain), perhaps one we’ve set up ourselves called an experiment(maybe used chiropractic methods on back pain), and collect data(asked the individual “whats changed?”). When we analyse this data,(how many people report an improvement) it tells us if our hypothesis truly describes the real world or not.(does chiropractic work) Either way we can now give a better hypothesis,(a reason as to why chiropractic works) a description of the world that is, in some way,(the best method of treatment) a better match to reality. This process, simple and elegant, has turned into a separate assessment target where we need to teach our kids ‘how science works’, as if it’s separate from all the facts we’ve discovered using it.

My reply:

For a medical treatment – or anything which claims to treat a health issue – there are two aspects to consider.

1) Does it work? (is it effective, which is not quite the same as does the patient say it helps.)
2) Is it safe?

Together, these two aspects will help qualified medical staff to make a judgement based on the benefit versus the risk. For chiropractic, There is a fair bit of evidence that it is about as effective as other manipulative therapies, such as physiotherapy or, for that matter, osteopathy, for back pain and related conditions. There is, as far as I’m aware, very little evidence to suggest it is at all effective for conditions such as asthma, ear infection or colic. You could argue that claiming – as many chiropractors have done, and for all I know you may have done – to treat these conditions with chiropractic is ‘bogus‘. And it is a matter of record that chiropractors over-use X-rays to ‘diagnose’ mythical subluxations, in direct opposition to NICE Guidelines. Of course, chiropractors generally (and their ‘professional’ association) have shown a rather poor understanding of research to date.

Which brings me nicely to the risk. There is evidence that a small number of ‘adjustments’, as performed by chiropractors, can lead to rather severe consequences, including stroke and death. Now, in medicine, if there is a risk of these kind of irreversible side-effects, we manage the risk. We make sure to try alternative treatments first. We check for sensitivity to drugs, and where necessary have crash-carts and trained personnel on hand. Chiropractors appear to lack the insight into possible consequences, which means they cannot adequately balance a non-zero risk against a benefit which appears minimal.

Talking about looking for evidence, or investigating ‘how’ it works, is an irrelevant distraction. In summary, the researchhas already been done, and like for so many other forms of alternative medicine, the result is the same. It doesn’t work much (if at all), and the risks – which are so rarely made clear to patients – mean it should be avoided if possible.

Are we done now?

I would welcome any useful links, clarifications or suggestions. Please note I feel that data is more inportant that anecdotes. The one point in his comment that I agree with is that it is odd in science teaching to divorce the scientific method from the evidence collected with it and the theories created by it. But then, like most science teachers I know, I don’t separate them. And if Liam’s teachers had made this clearer, perhaps he would find it easier to consider the data rather than the anecdotes and realise that the therapy he practises has significant issues.

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15 thoughts on “Getting Spammed By Mabus”

  1. Well thanks for that, though it’s not the first time I’ve been called a troll, I merely returned the favour of checking your website and quite liked it. I thought how you explained how to gather data was good and could maybe be used with chiropractic. Anyway to your blog.
    1 does it work? OK I simply put “whats changed”, but I would of thought you may have perhaps thought I was giving a very simple outcome. Most improvements in pain or dicomfort or restrictions are perceived improvements, right? I use pain scales, sometimes Oswestry low back pain scores, or Vernon & Mior cervical spinal scores, so if the patient reports an improvement on any of these scores they are saying they feel better. Is that wrong? Is it worse in the morn? Is it affecting sleep? Can you go to work? play sport? are you taking pain releif? if so how much for how long? does it help with the pain? All questions I ask and monitor over a course of treatment. So when I put “whats changed” Iam incorperating all the questions and scores I have used.
    Physiotherapists are not trained to manipulate, they have to take further training to do so, Again my brother is both a physiotherapist and a chiropractor and guess what he does all day.
    I don’t know what your name is but if you had checked your references you would perhaps have noticed what technique I use and the fact that McT chiropractors don’t take x-rays, I can refer for x-rays or MRI scans if I feel the need , but again McT don’t take xrays. Again if you had checked you would see that I’m not a member of the BCA.
    Again I have never seen a child under 8, except my own, and NEVER started treatment to try and improve any of the childhood illnesses you have mentioned. Infact I know a lot of chiropractors who have not done so.
    On to risk, again you obviously have not researched quite as well as you should. The McT technique does not use rotational neck adjustment, you will find no data regarding these serious adverse affects following a McT neck adjustment. That of course is not to say any other technique is dangerous far from it. There have been over 2000 chiros working in England for the last 20 years, literally seeing hundreds of thousands of patients, don’t you think the media would be awash with these horror stories if it was as dangerous as you think. Quoting anything from Mr Ernst does you no favours as I can quote Cassidy, the largest study of our time. Look it up, though Blue wode will say its biased etc, nothing like Mr Ernst studies.

    On to anecdotes, I don’t think you realise that these are not just anecdotes every person is a case study, I have 20 years of case studies, what data would you like me to collect? I will try and do it.

    Anyway got to go now very busy day.

  2. Liam Mulvany wrote: “Again I have never seen a child under 8, except my own, and NEVER started treatment to try and improve any of the childhood illnesses you have mentioned. Infact I know a lot of chiropractors who have not done so.”

    Nevertheless, the statistics show that many UK chiropractors treat children, and not just for musculoskeletal problems. For example, take a survey of 1,418 active and semi-active UK chiropractors in 2003. [Ref. Wilson FJH, A survey of chiropractors in the United Kingdom, European Journal of Chiropractic, 2003:50:185-198]. It had a response rate of 58% (816), and its participants included members of the British Chiropractic Association (BCA) and Scottish Chiropractic Association (SCA), educated at accredited colleges, and members of the (former) British Association for Applied Chiropractic (BAAC) and McTimoney Chiropractic Association (MCA), educated at unaccredited colleges but grandparented to practise in the UK. A strong majority of respondents (98%) considered the management of children to be within the scope of chiropractic practice, with a further 69% believing they could manage organic or visceral conditions. What’s more, those figures appear to be supported by a later (2006/2007) UK survey which showed that infantile colic, and childhood otitis media and asthma were perceived to benefit from chiropractic intervention by more than 50% of the respondents. Interestingly, 76% of chiropractors in that survey also deemed traditional chiropractic beliefs (chiropractic philosophy) to be important, giving a figure of 63% for chiropractors who considered the fictitious ‘subluxation’ lesion to be central to chiropractic intervention. [Ref. Aranka Pollentier and Jennifer M. Langworthy, The scope of chiropractic practice: A survey of chiropractors in the UK. Clinical Chiropractic, Volume 10, Issue 3, Pages 147-155. September 2007]

    Liam Mulvany wrote: “On to risk, again you obviously have not researched quite as well as you should. The McT technique does not use rotational neck adjustment, you will find no data regarding these serious adverse affects following a McT neck adjustment.”

    You seem to be forgetting the other harmful aspects of chiropractic which are: (a) decreased use of immunisation due to misinformation given to parents, (b) psychologic harm related to unnecessary treatment, (c) psychologic harm caused by exposure to false chiropractic beliefs about “subluxations,” and (d) financial harm due to unnecessary treatment.

    Liam Mulvany wrote: “There have been over 2000 chiros working in England for the last 20 years, literally seeing hundreds of thousands of patients, don’t you think the media would be awash with these horror stories if it was as dangerous as you think.”

    No, for two good reasons. Firstly, sometimes mild symptoms start immediately and progress after the patient leaves the chiropractor’s clinic. Sometimes an artery tear is a small one and it clots over; then days later the clot breaks loose, travels to the brain and causes a delayed stroke. By this time, the patient may not connect his/her sudden collapse to the previous visit to the chiropractor. Chiropractors do not follow up on every patient. Patients who have delayed strokes may never see their chiropractor again, so chiropractors would naturally tend to underestimate the risk. Also, many of these diagnoses could well be missed if the vertebral arteries are not examined on autopsy. And secondly, the UK Chiropractic Patient Incident Reporting and Learning System (the only system for recording adverse events – for use by chiropractors only) is underutilsed. Reasons identified for this include “fear of retribution, being too busy and insufficient clarity on what to report”. [Ref. Clinical Chiropractic, Volume 11, Issue 2, Pages 63-69 (June 2008)]

    Not very reassuring, is it?

    Liam Mulvany wrote: “Quoting anything from Mr Ernst does you no favours as I can quote Cassidy, the largest study of our time. Look it up, though Blue wode will say its biased etc, nothing like Mr Ernst studies.”

    Readers should be made aware that J David Cassidy in a trained chiropractor, whereas Professor Edzard Ernst is a career scientist. It is therefore fairly easy to guess who’s likely to be the more impartial. As for the Cassidy study, it’s worth noting that it only looked at head and neck pain chiropractic patients, yet chiropractic patients who have had a stroke as a result of neck manipulation have often been treated for problems unrelated to head and neck pain, such as low-back pain and general health problems or for “maintenance care” on asymptomatic patients. It’s also interesting to read what Sharon Mathiason, a mother whose daughter died following chiropractic neck manipulation for a tailbone injury, had to say in a letter in which she questioned Cassidy’s integrity:

    Quote:
    “The Globe and Mail [the publication in which the study was recently featured] is also negligent in not identifying the principal author, David Cassidy, as a chiropractor, one who has been sued in Saskatchewan, in 1999, by his research assistant for falsifying data, and one whose work is stated in the New England Journal of Medicine as “all of the study’s authors conclusions are completely invalidated by their methods”.

    More…
    http://www.chirowatch.com/Chiro-strokes/gm080120stroke.html

  3. Blue wode as you well know a child is classed as 16 and under, so the first quarter of your post is pointless.
    “were perceived to benefit from chiropractic intervention ” again perceived is the key word there, as you know our own associations and the GCC were supplying us with info that had these conditions in them. Perceiving chiropractic can help is not the same as putting it into practice.
    The subluxation is a term used to describe an area or joint that is to be adjusted, nothing more or less. It has other names when manipulation is carried out by a Physio, Osteopath or orthopedic surgeon, and you know that.
    Your explanation of a stroke is fine but of course this can happen, and has been documented, after having a hair cut or having your hair washed or even doing the gardening.
    “Chiropractors do not follow up on every patient. Patients who have delayed strokes may never see their chiropractor again, so chiropractors would naturally tend to underestimate the risk.” Again I’m afraid you are wrong, often a patient is asked to return and often the chiropractor follows up after the first visit.

    Mr cassidy was a chiropractor but is now a full time scientist, infact he does not see any patients at all. He started into research following stroke he thought was caused by chiropractic manipulation, he is a scientist that has provided us with the biggest study yet that shows you are no more likely to have a stroke after seeing a chiropractor than you are your GP.
    Mr ernst was himself practising spinal manipulation and homeopathy at one point wasn’t he? Apparently he was qualified, so why should he not be biased but Cassidy is?

  4. Liam Mulvany wrote: “ “were perceived to benefit from chiropractic intervention ” again perceived is the key word there, as you know our own associations and the GCC were supplying us with info that had these conditions in them. Perceiving chiropractic can help is not the same as putting it into practice.”

    But you must surely be aware that the most recent GCC survey of the UK chiropractic profession revealed that 60% of respondents said that they *treated* children from the age of 0-5, and 81% said that they *treated* children from the age of 6-15.

    Liam Mulvany wrote: “The subluxation is a term used to describe an area or joint that is to be adjusted, nothing more or less.”

    It is *the reason why* the joint is being adjusted that’s important. Many chiropractors view it as a panacea.

    Liam Mulvany wrote: “Your explanation of a stroke is fine but of course this can happen, and has been documented, after having a hair cut or having your hair washed or even doing the gardening.”

    But we’re talking about a responsible risk/benefit assessment for a therapeutic intervention – in other words, ethics come into play, i.e. first do no harm. In the case of chiropractic such an assessment is unfavourable.

    Liam Mulvany wrote: “ “Chiropractors do not follow up on every patient. Patients who have delayed strokes may never see their chiropractor again, so chiropractors would naturally tend to underestimate the risk.” Again I’m afraid you are wrong, often a patient is asked to return and often the chiropractor follows up after the first visit.”

    I think you’ll find you’re making a rather large assumption there. Here’s what Edzard Ernst had to say about 2007 AECC study, ‘Safety of chiropractic manipulation of the cervical spine: a prospective national survey’:

    Quote:
    “The sample of this survey was sizeable but not large enough to exclude rare events… The picture gets more complicated when considering the 698 treatment consultations of patients who failed to return for their next treatment. Theoretically some or most or all of these patients could have died of a stroke. *Overlooking even one single serious adverse event would change the estimated incidence rates from this study quite dramatically*. In my view, the most confusing aspect about the results of this survey is the fact that the incidence of minor adverse events is so low. Previous studies have repeatedly shown it to be around 50%. The discrepancy requires an explanation. There could be several but mine goes as follows: the participating chiropractors were highly self-selected. Thus they were sufficiently experienced to select low-risk patients (in violation of the protocol). This explains the low rate of minor adverse events and begs the question whether the incidence of serious adverse events is reliable.”
    http://onlinelibrary.wiley.com/doi/10.1111/j.2042-7166.2006.tb04794.x/abstract

    Liam Mulvany wrote: “Mr cassidy was a chiropractor but is now a full time scientist, infact he does not see any patients at all. He started into research following stroke he thought was caused by chiropractic manipulation, he is a scientist that has provided us with the biggest study yet that shows you are no more likely to have a stroke after seeing a chiropractor than you are your GP.”

    It does not show that at all. Do a search for Cassidy’s study at the Science Based Medicine website and read all the critical analyses of it.

    Liam Mulvany wrote: “Mr ernst was himself practising spinal manipulation and homeopathy at one point wasn’t he? Apparently he was qualified, so why should he not be biased but Cassidy is?”

    Because unlike CAM therapists, Professor Ernst has never depended on the “right” outcomes in studies in order to continue to earn a living – or, dare I say it, to salve his conscience for causing a catastrophic injury.

  5. Ok to your first point that 60% of respondents treat 0 to 5 years olds, lets first make it clear that that is 60% of 42% of chiropractors that actually took the time to reply to the gcc. so it’s not even representative of half the profession. Also a large number of respondents practiced wellness care.

    Chiropractors were asked to tick the options which they believed were:
    a) what they thought chiropractic could offer
    b) In reality, which of the options did they practice.

    Wellness care, promoting general health and helping to
    prevent the occurrence of disorders 659 (77.16%) 535 (62.64%)

    As you and I know wellness care chiropractors often state the benefit of starting chiropractic care very early and I feel that because 77% of chiropractors that completed the survey were wellness chiropractors this was always going to show a higher proportion of young children, even babies being treated. so 62% are wellness chiropractors so no wonder 60% treat 0 to 5.

    Again even if every chiropractor treated under 5s what is the problem? do you have any evidence of harm to under 5 s following chiropractic manipulation? No? then if first do no harm is your view where is the harm? Ok is it about money?

    “Children under 5 – Free” taken from a chiropractic web site.
    So many chiropractors see children under 5 for free and there is no evidence of harm following chiropractic care, what exactly is your argument?

    “It is *the reason why* the joint is being adjusted that’s important. Many chiropractors view it as a panacea”

    I don’t agree, a joint is adjusted because its misaligned , stuck call it what you will but the adjust or manipulation is done to correct something again that something can be called a subluxation or fixation or what ever. Ask Mr Ernst what he was doing when he used spinal manipulation, what was he actual trying to do/ correct?

    “But we’re talking about a responsible risk/benefit assessment for a therapeutic intervention – in other words, ethics come into play, i.e. first do no harm. In the case of chiropractic such an assessment is unfavorable. ”

    Again I don’t agree and like your friend Mr Ernst you like to cherry pick, below is some data taken from the same study.

    Patients received from other healthcare practitioners within the last working month:
    _ 76% (the greatest proportion) were received from GP recommendations.

    Chiropractors were asked if they currently shared premises with any other healthcare
    practitioners, in their capacity as a chiropractor
    Medical Dr 96 (11.24%)

    Chiropractors were asked to identify if they had received patients from a list of
    healthcare practitioners within the last working month.
    Number of chiropractors
    who received patients
    referred from another healthcare
    professional, in the
    Healthcare professional last working month % of Respondents
    Chiropractor 466 54.56%
    GP 646 75.64%
    Consultant in private practice 127 14.87%
    NHS consultant 10 12.52%
    Osteopath 34 3.98%
    Physiotherapist 123 14.40%
    Acupuncturist, homeopath
    or medical herbalist 181 21.19%

    Not only are Gps referring to chiropractors but 11% work with GPs, so is safety an issue for the 75% of chiropractors in this study that had GP referrals?

    Onto the Aecc study, using anything from Mr Ernst is never a good start, This has been said about Mr Ernst.
    ” He’s been especially critical of chiropractic and, in the opinion of many researchers, has glossed over important research and exaggerated results.”
    “By example, a recent ‘systematic review’ of individualised herbal medicine
    undertaken by Ernst and colleagues started with 1345 peer-reviewed studies.
    However, all but three (0.2%) of the studies (RCTs) were rejected.”

    And again here a great insight into how the great Prof works.
    http://www.neuraltherapie-blog.de/?p=1620

    Ok back to the AEEC study lets get the figures shall we,

    “We studied treatment outcomes obtained from 19,722 patients”

    “Data were obtained from 28,807 treatment consultations and 50,276 cervical spine manipulations. There were no reports of serious adverse events.”

    “What” said blue wode and Mr Ernst NO adverse effects, no I’m not having that There must be something wrong!!!

    Check the numbers 19722 patients with 50276 manipulations and no adverse affects. How can you class that as dangerous? how much data do you need?

    As for Mr Cassidy I will leave you with this.

    “Dr. Cassidy is a Senior Scientist in the Division of Health Care Outcomes and Research at the Toronto Western Research Institute, Professor in the Division of Epidemiology at the Dalla Lana School of Public Health and Professor in Clinical Epidemiology in the Department of Health Policy, Management and Evaluation in the Faculty of Medicine at the University of Toronto. He also holds the Research Directorship in Artists’ Health at the University Health Network.
    Originally trained as a chiropractor, Dr. Cassidy practiced in both Ontario and Saskatchewan, where he was a member of the Medical-Dental Staff at the Royal University Hospital and a consultant chiropractor to the Division of Orthopedic Surgery. He also holds a Bachelor’s degree in Anatomy, a Master of Science in Surgery and a Doctorate in Anatomical Pathology from the University of Saskatchewan. His second doctoral degree (Dr.Med.Sc.) was earned in Epidemiology and Injury Prevention at the Karolinska Institute in Stockholm, Sweden.
    Dr. Cassidy has authored over 225 scientific papers and chapters in books, including publications in the New England Journal of Medicine, Achives of Internal Medicine, Spine and other international journals. His research interests include musculoskeletal and injury epidemiology. His current research focus is on disability prevention from occupational and traffic injuries, neurotrauma (brain and spinal cord injury) and health issues in artists. ”

    Please don’t lower yourself to think he only did the research to clear his conscience, he is a scientist who was once a chiropractor and if you don’t think his research is up to scratch why don’t you go and tell him?

  6. Liam, I’m going to number your points (such as they are) to make it easier to follow.

    1 – survey maths
    “Ok to your first point that 60% of respondents treat 0 to 5 years olds, lets first make it clear that that is 60% of 42% of chiropractors that actually took the time to reply to the gcc. so it’s not even representative of half the profession. Also a large number of respondents practiced wellness care.”

    Unless you believe there is a link between the kind of care provided and the probability of responding, that is *exactly* what we can do. That’s the simultaneous strength and weakness of surveys.

    2 – survey answers
    “Chiropractors were asked to tick the options which they believed were:
    a) what they thought chiropractic could offer
    b) In reality, which of the options did they practice.

    Wellness care, promoting general health and helping to
    prevent the occurrence of disorders 659 (77.16%) 535 (62.64%)

    As you and I know wellness care chiropractors often state the benefit of starting chiropractic care very early and I feel that because 77% of chiropractors that completed the survey were wellness chiropractors this was always going to show a higher proportion of young children, even babies being treated. so 62% are wellness chiropractors so no wonder 60% treat 0 to 5.”

    This would only be true *if* you could show that all of those who said they treated 0-5 year olds were what you call ‘wellness care chiropractors’. Perhaps there is a high overlap, but I don’t think you can be confident of this, especially as some (many?) chiropractors claim, *without evidence*, to be able to treat conditions such as colic. Personally I suspect that accounts for several of these. Q: What do you feel about the use of chiropractic treatment to treat colic (and other conditions such as asthma) where reviews have shown it to be ineffective?

    3 – children, chiropractic and charging.
    “Again even if every chiropractor treated under 5s what is the problem? do you have any evidence of harm to under 5 s following chiropractic manipulation? No? then if first do no harm is your view where is the harm? Ok is it about money?

    “Children under 5 – Free” taken from a chiropractic web site.
    So many chiropractors see children under 5 for free and there is no evidence of harm following chiropractic care, what exactly is your argument?”

    Firstly, my argument would be about benefit vs risk. Perhaps none of the techniques shown by research to be dangerous (high velocity cervical for example) are ever used with children. Even short-term discomfort is only justified if there is benefit, which is unclear for many conditions for which chiropractic is used for children.

    Secondly, *one* chiropractor treating under fives for free isn’t a pattern – and even if it was, so what? It’s about medicalising childhood, offering ‘preventative’ treatment which is of no benefit, and so getting child and parent used to the idea that chiropractic treatment is needed for health. I see it as a danger sign, a way to bring in more business, not as altruism. Theme parks and holiday companies do the same thing, after all…

    4 – why adjust?
    ” BW: “It is *the reason why* the joint is being adjusted that’s important. Many chiropractors view it as a panacea”

    I don’t agree, a joint is adjusted because its misaligned , stuck call it what you will but the adjust or manipulation is done to correct something again that something can be called a subluxation or fixation or what ever. Ask Mr Ernst what he was doing when he used spinal manipulation, what was he actual trying to do/ correct?”

    A large number of the misalignments that chiropractors claim to see, for example on X-rays, are very much subject to interpretation. This is an old investigation, for example, but I’d be very interested to see the results of a similar approach in the UK now: http://www.quackwatch.org/01QuackeryRelatedTopics/chiroinv.html
    Also NICE recommended *against* the use of X-rays and other treatments for back pain. http://www.nice.org.uk/usingguidance/donotdorecommendations/search.jsp?action=dndByGuidance&guidanceId=11887
    Q: Do you use X-rays as part of diagnosis?

    5 – Chiropractic Treatment and Stroke
    “BW: “But we’re talking about a responsible risk/benefit assessment for a therapeutic intervention – in other words, ethics come into play, i.e. first do no harm. In the case of chiropractic such an assessment is unfavorable. ”

    Again I don’t agree and like your friend Mr Ernst you like to cherry pick, below is some data taken from the same study.”

    Before I engage with the numbers, I’d say you’ve really – deliberately? – misinterpreted @Blue_Wode’s response. He was answering your claim that you can have a stroke after a haircut or doing the gardening, the subtext being that you can’t blame chiropractic treatment.
    Q: Are you saying that you don’t believe that in the cases documented, that there was a link between treatment and injury?

    6 – Referrals
    “Patients received from other healthcare practitioners within the last working month: _ 76% (the greatest proportion) were received from GP recommendations.

    Chiropractors were asked if they currently shared premises with any other healthcare practitioners, in their capacity as a chiropractor
    Medical Dr 96 (11.24%)

    Chiropractors were asked to identify if they had received patients from a list of
    healthcare practitioners within the last working month.
    Number of chiropractors who received patients referred from another healthcare
    professional, in the Healthcare professional last working month % of Respondents
    Chiropractor 466 54.56%
    GP 646 75.64%
    Consultant in private practice 127 14.87%
    NHS consultant 10 12.52%
    Osteopath 34 3.98%
    Physiotherapist 123 14.40%
    Acupuncturist, homeopath
    or medical herbalist 181 21.19%

    Not only are Gps referring to chiropractors but 11% work with GPs, so is safety an issue for the 75% of chiropractors in this study that had GP referrals?”

    That’s a really interesting statistic – from the links above I’m not sure which study it somes from. However you are making a slight error in assuming that all of the medical doctors sharing premises with chirppractors are GPs. I strongly suspect the vast majority are not, instead being in private practice. Of course you may have data to contradict me. Also you (or someone else) has misplaced the decimal point for NHS consultants; by comparison with the others it should be 1.252%.

    And apart from anything else, that almost a quarter have received referrals from acupuncturists, homeopaths or medical herbalists (I’d class all of these as ‘amateur magicians’ rather than clinical medical staff) is a condemnation rather than a recommendation. I wonder how the GPs and NHS consultants would feel, being in that company?

    7 – Bias
    “Onto the Aecc study, using anything from Mr Ernst is never a good start, This has been said about Mr Ernst.
    ” He’s been especially critical of chiropractic and, in the opinion of many researchers, has glossed over important research and exaggerated results.”
    “By example, a recent ‘systematic review’ of individualised herbal medicine
    undertaken by Ernst and colleagues started with 1345 peer-reviewed studies.
    However, all but three (0.2%) of the studies (RCTs) were rejected.”

    And again here a great insight into how the great Prof works.
    http://www.neuraltherapie-blog.de/?p=1620

    Without saying where these quotes come from, they’re meaningless. A quick Google search shows the source of the first is an #altmed podcast site which sells ‘cold lasers’ for pain relief and is run by a chiropractor. http://ontheotherhand.podbean.com/

    Find people who aren’t alternative medicine practitioners who criticise him and I’ll listen. As for the high rejection rate mentioned, it’s standard that a systematic review will reject a lot of papers. Rejection rates are often higher for altmed because the size tends to be smaller and the quality tends to be lower.

    8 – Adverse Events
    “Ok back to the AEEC study lets get the figures shall we,

    “We studied treatment outcomes obtained from 19,722 patients”

    “Data were obtained from 28,807 treatment consultations and 50,276 cervical spine manipulations. There were no reports of serious adverse events.”

    “What” said blue wode and Mr Ernst NO adverse effects, no I’m not having that There must be something wrong!!!

    Check the numbers 19722 patients with 50276 manipulations and no adverse affects. How can you class that as dangerous? how much data do you need? ”

    Maybe you should reflect on the difference between “no adverse events” and “No reports of adverse events”. In fact, I’d like your answer to a hypothetical case:
    Q: If a patient of yours had side effects *after* seeing you, but did not have another appointment booked, would you ever find out?

    9 – Cassidy
    “As for Mr Cassidy I will leave you with this.

    “Dr. Cassidy is a Senior Scientist in the Division of Health Care Outcomes and Research at the Toronto Western Research Institute, Professor in the Division of Epidemiology at the Dalla Lana School of Public Health and Professor in Clinical Epidemiology in the Department of Health Policy, Management and Evaluation in the Faculty of Medicine at the University of Toronto. He also holds the Research Directorship in Artists’ Health at the University Health Network.
    Originally trained as a chiropractor, Dr. Cassidy practiced in both Ontario and Saskatchewan, where he was a member of the Medical-Dental Staff at the Royal University Hospital and a consultant chiropractor to the Division of Orthopedic Surgery. He also holds a Bachelor’s degree in Anatomy, a Master of Science in Surgery and a Doctorate in Anatomical Pathology from the University of Saskatchewan. His second doctoral degree (Dr.Med.Sc.) was earned in Epidemiology and Injury Prevention at the Karolinska Institute in Stockholm, Sweden.
    Dr. Cassidy has authored over 225 scientific papers and chapters in books, including publications in the New England Journal of Medicine, Achives of Internal Medicine, Spine and other international journals. His research interests include musculoskeletal and injury epidemiology. His current research focus is on disability prevention from occupational and traffic injuries, neurotrauma (brain and spinal cord injury) and health issues in artists. ”

    Please don’t lower yourself to think he only did the research to clear his conscience, he is a scientist who was once a chiropractor and if you don’t think his research is up to scratch why don’t you go and tell him?”

    Liam, this is very interesting. @Blue_Wode challenged you to read articles explaining *why* Cassidy’s ‘research’ was flawed. Your response is to cut and paste Cassidy’s bio from somewhere. I’ve just read through some, not all of the information (I will, don’t worry) but perhaps you might like to do the same? Either you care about CPD and evidence-based medicine as you claimed, or you are just using the terms to justify your chosen career. Showing yourself to be ignoring the data is not a promising sign of commitment. One of the articles is here: http://www.sciencebasedmedicine.org/?p=5897

    Finally, can I repeat my offer to post the URL for your Chirobase article here, when you hava the opportunity. I’m sure I’m not the only person who would be interested in reading and commenting on it.

    EDIT: Liam has pointed out on Twitter that I have not justified my claim that chiropractic offers little or no benefit. Let me clarify: there is a fair bit of evidence that chiropractic appears to offer roughly equivalent pain relief to other manipulative techniques for back pain. I am, however happy that there are many other conditions for which it is (unsurprisingly) useless, despite chiropractors’ claims to the contrary. These would include (but not be limited to) colic and asthma, treated bogusly by some chiropractors. He has also pointed out that Ernst comments that NSAIDs are also risky. I would counter, of course, that as medical staff engage with risks and side effects (via effectively used yellow card system) they are still far in front of chiropractors.

  7. A quick reply.

    Ian to your point 1 & 2. Over 77% of the chiros that replied stated they were wellness care chiros, obviously I don’t “beleive” there is a link the figures prove a link, a much higher proportion of chiros that responded were wellness. I can be confident that all 77% of chiros that responded and called themselves wellness are more likely to treat 0-5 years old.
    “Even short-term discomfort is only justified if there is benefit, which is unclear for many conditions for which chiropractic is used for children.” I agree, I cannot see a “musculo skeletal” reason for working on an under 5 year old. But if the child does benefit in “some way” and there is no danger what is your objection? Do you really think some parent is going to place their child into somebodies hands if they did not think there was some benefit and no risk, anecdotal or not?

    Ian, have you not read anything I have written to BW? I do not take xrays, the majority of chiros in the UK do not take x rays.

    “A large number of the misalignments that chiropractors claim to see, for example on X-rays, are very much subject to interpretation.” Again i agree but the skill in recognising what needs to be worked on is what defines a good therapist.

    “Q: Are you saying that you don’t believe that in the cases documented, that there was a link between treatment and injury? ”

    I can not rule that out, but can you rule out the possibilty that the person hadn’t just had their haircut prior to treatment? I know a doctor who suffered a VAD after giving evidence in court, it was put down to elevated blood pressure and stress, if he had seen a chiro any time the week before, the chiro would have got the blame. If there is a chance of a spontanous episode can you rule out the possibility that it was coincidence?

    “And apart from anything else, that almost a quarter have received referrals from acupuncturists, homeopaths or medical herbalists (I’d class all of these as ‘amateur magicians’ rather than clinical medical staff) is a condemnation rather than a recommendation.”

    I think thats what you scientists call a straw man, why can’t you accept the fact that GPs do send people to us? It happens all the time.

    As for your link to Dr Crispin, have you read the comments? Please do, some pull his theory apart aswell, infact he has added this.

    “Since the initial post, thanks to the comments, I have come up with an alternative hypothesis to account for the data. Like the authors, it is neither proven nor disproved by the data, but I think has more plausibility than their explanation.”

    More later.

  8. “He has also pointed out that Ernst comments that NSAIDs are also risky. I would counter, of course, that as medical staff engage with risks and side effects (via effectively used yellow card system) they are still far in front of chiropractors.”

    I would like to see how that yellow flag system works with repeat prescription. You have to actual speak to the patient for that to work.

    “Maybe you should reflect on the difference between “no adverse events” and “No reports of adverse events”. In fact, I’d like your answer to a hypothetical case:
    Q: If a patient of yours had side effects *after* seeing you, but did not have another appointment booked, would you ever find out?”

    You can’t have it both ways, there were no reports of adverse effects, to say there may have been some but we didn’t here about it is not very scientific.

    A: if a patient had an adverse effect after a visit to me and they did not have another appointment it’s perfectly reseonable to say I may not find out, though I may get to speak to them during a follow up phone call, I may get a telephone or letter of complaint or even a letter from a solicitor claiming damages, I think if I had gone to visit someone and I perceived they had “hurt” me they would get to know about it somehow. What would you do?

    i have a hyperthetical question for you.

    What would you do if you had been in pain for months, maybe years. You had seen your GP many times and tried most pain killers even though they made you constipated or feel ill or spaced out. you don’t want to keep taking these tablets but they take the edge of the pain. You would like to start playing sports again but every time you do your pain gets worse. You’ve been to see the physio at the hospital and the exercises they gave you seemed to make you worse and then they signed you off. You had an MRI and saw the consultant who said hes not going to operate.

    What would you do?

    I do actually hear this quite often, what should i do?

  9. “Mark Crislip wrote:

    The study says nothing about the safety of chiro…

    I agree with that. Or at least, it merely says chiro is not so wildly unsafe that they could detect it with their insensitive analysis.

    …and suggests it is not safe in the young.

    I still don’t see this part. The OR for VBA stroke within 1 day of a chiro visit was not different than the OR for VBA stroke within 1 day of a PCP visit. Chiro was no more likely to be associated with stroke than was a visit to the PCP. I saw nothing else in the paper to suggest that chiro caused VBA stroke.

    Please understand – I’m not arguing that chiro is not a cause of stroke. I’m only questioning your interpretation of this specific paper.”

  10. Returning to the numbered points:

    1 and 2) 77% of those who responded are those who would class themselves as ‘wellness practitioners’. You seem to think this figure is *not* representative of the profession. Can you explain why? And saying that ‘you are confident’ that there is a total(?) overlap between these ‘wellness’ chiropractors and those who treat children is irrelevant. Data, please.

    2) You have not answered the question. How do you feel about chiropractors who claim to treat asthma and colic in children despite evidence showing it is ineffective?

    Quoting papers looking at non-chiropractic treatment in animals (http://jap.physiology.org/content/48/5/862.abstract) is no way to contradict comprehensive reviews of chiropractic treatment in humans that do not show a benefit for asthma treatment. (http://www2.cochrane.org/reviews/en/ab001002.html) As a comparison, the best chiropractors can come up with is what they call a review, but includes case studies, questionnaires and surveys – do i need to explain the weaknesses? http://www.ncbi.nlm.nih.gov/pubmed/20195423

    3) You are missing the point. Parents, like everyone else, rely on professionals to correctly inform them about benefits and risks. I assume the pilot of a plane knows what they are doing – I trust their professional training and judgement. That parents seek out a therapy, or are willing to try it, means *nothing* except that they may be desperate. Perhaps you should consider the ethics of a profession claiming to offer benefits to people who are so desperate?

    Oh, and as far as X-rays are concerned – there’s some interesting analysis of the GCC’s own questionnaire (which I know doesn’t reflect all chiros) suggesting that in fact X-ray use is fairly routine in chiropractic care: http://www.quackometer.net/blog/2009/01/is-chiropractic-x-raying-illegal.html
    If you have data regarding X-ray use for non-GCC practitioners I’d be very interested.

    4) No. If several therapists given the same information diagnose different causes and suggest different treatments – as happened in Canada – then it raises serious questions about the quality of their training and professional skill. Did you read the link?

    5) You raise a good point that it would be easy to point the blame at chiropractic treatment for someone suffering a stroke soon after – but then that is just what you are doing, blaming hairdressers! I think you’ll find that the post-mortems, when carried out, show characteristic damage to the arteries, more usually found in car accident victims. I will ask you again to answer this without deflection: do you have *data* to contradict the findings that there is a *small* but measurable risk of stroke after use of *some* chiropractic techniques? I think I gave you this link before but I don’t know if you’ve read it. http://www.sciencebasedmedicine.org/?p=5897

    6) That 75% figure is very interesting – of course it is that 75% of chiropractors at some point in the past have had at least one referral from a GP, and doesn’t say what for. I would be very interested in those survey figures – do you have a link?

    And I think you’ve misunderstood the idea of a straw man; I think it is very telling that chiropractors accept referrals from acupuncturists, homeopaths and medical herbalists. I’d love to see how many referrals they send as compared to GPs, for example.

    7) For bias, see my earlier link about asthma; a chiropractor includes case studies and survey results in a systematic review. These are usually considered ‘low-quality’ compared to RCTs and similar in medicine, due to the many problems with confirmation bias, self-selection etc.

    I’ve no idea what you’re referring to with this about Dr Crispin – perhaps you can be more specific?

    8) I think most medical doctors would agree that if, say 10% of patients report side effects of a treatment in normal practice then there are *more* who don’t report it; this is particularly noticeable with men, and even more so with side effects which are seen as embarassing or personal (erectile dysfunction for example is considered to be greatly under-reported). It’s interesting that you can be so confident that there are *no* adverse events. At least you accept that patients might have adverse events that you never find out about.

    9) You have still not commented on why you feel the criticisms made of Cassidy could best be answered by cutting and pasting his bio, rather than reading the criticisms.

    10) Hypothetical questions: I completely accept that people experience pain – in many cases intractable, long-term pain. It affects their life, changes the activities they can participate in. (I should point out that I was a volunteer respite carer, then a care assistant, for a total of seven years.) I think you’ll find most people, including @Blue_Wode and many others offering criticisms of CAM (including but not limited to chiropractic) go to great lengths to recognise this.

    That *doesn’t* mean that you can fix them, or that chiropractic works. It raises major issues about *any* treatment that has not been shown to *work*. Now, there are some very interesting discussions to be had about the use of *safe* placeboes for *some* conditions. I would however say that offering – and of course charging for – treatments that have *not* been shown to be effective and *have* been shown to be potentially harmful could be seen as exploitation of people in a very vulnerable situation.

    Please could you, as I have done, take your time to put together readable responses to these points? It makes it much easier to follow your arguments if you do so, and is a much more effective way of engaging with specific ideas than posting links on twitter.

  11. Liam Mulvaney wrote: “Ok back to the AEEC study lets get the figures shall we, “We studied treatment outcomes obtained from 19,722 patients” “Data were obtained from 28,807 treatment consultations and 50,276 cervical spine manipulations. There were no reports of serious adverse events.” “What” said blue wode and Mr Ernst NO adverse effects, no I’m not having that There must be something wrong!!! “

    FYI, Professor Edzard Ernst questioned the integrity of the methodology used in that survey [Thiel HW, Bolton JE, Docherty S, Portlock JC – Safety of chiropractic manipulation of the cervical spine: a prospective national survey. Spine 2007 Oct; 32(21): 2375-8] and highlighted the very real problem of “having to rely on the honesty of participating therapists [chiropractors] who could have a very strong interest in generating a reassuring yet unreliable picture about the safety of their intervention”:

    Quote:
    “This is a most laudable attempt to define how often serious adverse effects of cervical manipulation happen. To generate certainty, such studies need to be very large, must not lose patients to follow-up and have to rely on accurate reporting. The sample of this survey was sizeable but not large enough to exclude rare events. Thus the authors can only state that, at worst, the risk of serious adverse events within 7 days after manipulation is 2 per 10,000 treatment consultations. If the average patient has a series of 10 treatments, this risk could therefore be as high as 1 in 500 per patient. Given the nature of the risk, i.e. stroke or death, this is by no means negligible.
    The picture gets more complicated when considering the 698 treatment consultations of patients who failed to return for their next treatment. Theoretically some or most or all of these patients could have died of a stroke. Overlooking even one single serious adverse event would change the estimated incidence rates from this study quite dramatically.
    In my view, the most confusing aspect about the results of this survey is the fact that the incidence of minor adverse events is so low. Previous studies have repeatedly shown it to be around 50%. The discrepancy requires an explanation. There could be several but mine goes as follows: the participating chiropractors were highly self-selected. Thus they were sufficiently experienced to select low-risk patients (in violation of the protocol). This explains the low rate of minor adverse events and begs the question whether the incidence of serious adverse events is reliable.
    Studies of this nature are very difficult to conduct such that we can trust the results. One of the problems is that one has to rely on the honesty of the participating therapists who could have a very strong interest in generating a reassuring yet unreliable picture about the safety of their intervention.”
    [Ref: Ernst, E. ‘The safety of chiropractic cervical manipulation’
    Focus on Alternative and Complementary Therapies, Vol.13. Issue 1. March 2008, pp43-44]

    Interestingly, in their response, two of the survey’s authors, JE Bolton and HW Thiel, claimed that, in the UK alone, there were an estimated *four* million manipulations of the neck carried out by chiropractors each year. Yet, six months earlier, in October 2007, in a letter to the Journal of the Royal Society of Medicine ( http://jrsm.rsmjournals.com/cgi/content/full/100/7/330 ), they claimed that the figure was “estimated to be well over *two* million cervical spine manipulations”. How that estimate could double in under six months is anyone’s guess, but it leaves them open to accusations that they may be trying to play down the risks.

  12. Ian a v quick reply. You miss understand about asthma. I was merely offering a possible reason as to why there mat be anecdotal evidence about asthma improving after chiro. I don’t believe it makes a jot of difference to the disorder asthma, but by improving the function of the articulations that actually enable us to breath will improve the mechanics of the breathing action. Therefore somebody with asthma may feel it has improved after chiro because they feel they can breath easier.
    This fix them thing drives me mad. I’m not a mechanic. And as for chiro not being shown to work, could you tell me what techniques were used during these studies? Or do you think all chiros are the same? According to research chiros x ray to much. I don’t. According to research chiros use poss dangerous neck rotation adjustments. I don’t. According to research chiros routinely adj the neck. I don’t. According to research chiros treat children for asthma and colic. I don’t. Need I go on?
    More later.

  13. Hello Ian
    Here is another hypothetical question for. Let’s say your school has an offsted report and that report said you were failing your pupils, the school was not attaining the results it should. Now even if your pupils were gaining the necessary grades would you still feel the report was a fair reflection of your outcomes? Should you be held responsible for the schools failings.

  14. Liam

    I’m finding this very frustrating. Let me make several points in one comment.

    Chiropractic

    * Suggesting possible mechanisms for perceived improvement is irrelevant when studies have shown that there is, at best, a lack of evidence for any objective improvement.

    * In my last comment – over 30 minutes work of reading, taking my time to respond and check links and sources online – I tried very hard to avoid any mention or ask any question about *your* clinical practice. I am talking about the profession you say you are part of. You have a choice; either condemn those colleagues using dangerous methods and treating conditions (e.g. asthma) without evidence, bring evidence to contradict those systematic reviews, or admit that you remain silent when you believe harm is being done.

    Blog Comments

    * Please take your time to write a single coherent comment, instead of ‘quick replies’ that invariably miss the entire point.

    * Answer the questions or don’t bother replying. Each time you avoid, evade or misunderstand them you only damage the poor impression I, and possibly many others, already have of those who call themselves chiropractors. I suspect that to anyone reading the comments – and I don’t for a minute think that there are many – it will seem that @Blue_Wode and myself have taken much more time to investigate chiropractic methods, claimed benefits and risks than you have, which is surely the wrong way around.

  15. Despite my earlier invitation @chirozilla did not visit the blog before comments closed, so I am adding his contribution here. I suggested email and he chose twitter, hence the brief nature of his response:

    “The research has not yet been done into whether or not the multi-modal approach works. But neither is there positive evidence that it does. In the light of this: serious consent is key in overcoming the acute lack of evidence in the light of possible risks. That said there is no basis to state it doesn’t work. Research is needed.”

    I find it interesting that he believes this somehow counters my argument – perhaps he hasn’t fully read the previous comments.

    I have not been discussing the use of chiropractic for *all* conditions, but the ethics and concerns with claiming it is effective in treating conditions such as asthma and colic. He has not addressed this. I have pointed out that chiropractors give isolated case studies and anecdotes in a misguided attempt to refute systematic reviews, such as those carried out by Edzard Ernst. He has not addressed this, instead claimed, as altmed practitioners often do, that ‘research is needed. He has acknowledged the risks but perhaps did not read the comments I and @Blue_Wode made suggesting that ignoring these risks raises questions about the ethical position of individual chiropractors and of the profession as a whole.

    As far as I’m aware, @Liam_Mulvany has not yet produced the article he talked about so there is no forum to continue our discussion. As the comments above show, he repeatedly failed to respond to basic questions and refused to condemn chiropractors who made false claims and failed to address very real concerns about potential risks.

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