Beware the spinal trap

Today, bloggers all around the world are re-publishing an edited version of Simon Singh’s article that lead him to be sued by the British Chiropractic Association. I’m happy to reproduce the article here. Not because I am against alternative therapies, but because I think it is dangerous to use libel laws to stifle legitimate scientific – i.e. empirically tested – opinions and theories.

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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20 Responses to Beware the spinal trap

  1. sledpress says:

    I would say chiropractors and medical doctors are entitled to be judged on the same level. Speaking as a massage therapist who has used chiropractors for over thirty years and worked professionally with them for over twenty, I’d like to remark that no chiropractor, in my case or any I’ve been aware of, has been the cause of the ill effects alleged in this article to occur in “fifty per cent of” their clients. You have to wonder who is being interviewed.

    The number of severe or fatal injuries incurred by ANY treatment for pain or illness should be, obviously, zero. Funnily enough, when even one incident like this is reported in the case of a non-medical treatment, you hear about it in horrendous detail. The same people who get into a fantod about chiropractors brush off anything bad that happens in the course of treatment by MDs as necessary evils in the pursuit of some sort of Health Righteousness, or so it seems. Nobody tars the whole medical profession over death and illness from polypharmacy, overtreatment, invasive testing, and the like; as for allegations that chiropractors don’t help people much, you have to wonder why some folks keep coming back to them for decades. I can’t remember the last time one gave me a “high velocity thrust.”

    I once had a painful elbow submerged in a hot water bath by a college clinic nurse who ranted at me when I mentioned I might ask my chiropractor about it, storming that she had had FIVE back operations and she would NEVER go to a chiropractor. The elbow turned out to be infected and her hot water bath accelerated the infection so that my arm blew up like a balloon exactly to the points it had been submerged. I didn’t go on a tear about how stupid clinic nurses and their hot water baths should be taken off the market.

    Tylenol is involved in thousands of emergency room admissions for acute liver failure EVERY YEAR. It’s typically treated as an innocuous drug and stuck into dozens of patent formulations without any conspicuous warning not to combine those formulas, drink alcohol at the same time, etc. I humbly submit that if an herbal supplement, for example, had ever been shown to do the same harm, the entire herbal industry would have been proscribed — it seems to me the bias of belief in harmlessness and effectiveness is still strongly on the side of medical therapies.

    It may not be libel to discuss candidly when people are hurt by something that’s supposed to help, but people who talk about MDs and drugs the way this article talks about chiropractors — dwelling on details of harm incurred and alleging ineffectiveness — are dismissed as cranks.

  2. modestypress says:

    This is a topic that hits close to home. My family on my father’s side was deeply involved in “alternative medicine.” I regard much of what they did as quackery. But some of it wasn’t. The problem is figuring out which is which.

    Much of conventional medicine is quackery. But not all of it is. Same problem.

    Quack quack.

  3. woo says:

    My point is not that alternative medecine is quackery – as I said, I have no problem with alternative medecine and know of many instances where alternative medecines and therapies have been of benefit to people I know, as well as instances where conventional medecine has been, if not downright harmful, then certainly unhelpful.

    My point is that nobody, expressing a scientific opinion which they have based on empirically tested evidence, should be sued for libel in this way.

    So, any kind persons who are poised to write further in support of various alternative madecines and therapies can save yourself the trouble. This is not a post about alternative medecine. It is about the British legal system – specifically, our absurd libel and defamation laws. I simply think the burden of proof should lie with the organisation bringing the libel case, not with the individual accused.

  4. sledpress says:

    Well, the point which I may not have emphasized enough is that the public mind-set is such that you would be regarded as a lunatic for calling out individual medical doctors or accepted medical practices and saying they should be proscribed or put out of practice because of the harm they cause. But no one seems to think it’s outrageous when you report similar outcomes — which in this article look heavily massaged to me, no pun intended — about an alternative therapy and jump from there to saying it should be banned. Libel suits may not be the best riposte but what other means are available to the chiropractic profession to counteract this sort of partisan witch-hunting, fueled by statements about the proportion of negative side effects which I find highly suspect?

  5. woo says:

    I do see what you mean, and I agree, Sledpress. Let everyone play by the same rules, absolutely. So, the British Chiropractic Association had the opportunity to answer Simon Singh’s deliberately controversial (in that it sought to spark an open debate) article in the Guardian with one of their own, so that readers could make up their own minds, but they chose not to. Instead, they chose to use their considerable resources to hound a man through the courts.

    Also, if we’re going to insist on everyone playing by the same rules – and I think we should, too – then chiropractice needs to be subject to the same rigorous scientific testing as conventional medicine. With large samples, blind controls, placebo tests etc. That way we’d see whether it was genuinely effective, either physiologically or psychologically.

    Again, though, let me reiterate that I don’t have a problem with chiropractors or any other alternative therapy in and of themselves. Its this particular instance of an attempt to stifle debate using the courts with which I disagree.

  6. This is pretty darned interesting.

    Devil’s advocate … while I don’t agree that libel suits should be used to silence debate, I might suggest a couple of things:

    1) That there is no such thing as impartial empirical testing, even in science. There are, yes, controlled tests, etc … but even those are pretty darned subjective, often failing to take into consideration such important factors as the weights and genders of the subjects, which partly explains why people have such vastly different reactions to drugs “proven” to be safe. Cynic that I am, I’m not sure anecdotal evidence of efficaciousness is any less reliable than many science-based safety tests.

    2) The testing that would be demanded to “prove” the validity of alternative medicine would be very time-consuming and very expensive, which would impact the affordability of it … which is currently one of its benefits to those who seek it out.

    So it seems to me that one reason alternative medicine may resort to unfair tactics such as these is to kind of … balance out the unfairness inherent in the system, if that makes sense. I’m not saying that’s right or wrong; I’m just musing. 🙂

  7. woo says:

    Hmmm, an interesting view of the issue. And I take your points – we’re almost back trying to compare apples and oranges in some ways, aren’t we?

    And while I see what you mean about there being so many variables that even empirical scientific testing isn’t truly impartial or above error, my concern with anecdotal evidence of efficaciousness would be that it tends to take even less account of the individual circumstances of the patient. “My friend found that chiropractice really helped her headaches, you should try it, too” when the friend’s headaches are caused by sitting at a computer screen all day and yours are caused by a tumour…

    However, on the plus side, I do tend to believe that most of us, by the time we reach our early thirties, know our own bodies much better than any one else is ever going to, doctor or not.

    As to the point about alternative therapies being more affordable because they don’t have the overheads of conventional medicine in terms of time-consuming and expensive testing, again I’d say that could be seen as a con as much as a pro. Especially if it is actually doing no real good, or possibly even more harm than good. The most vulnerable people in our societies would often be the ones affected by that.

    Unfairness in any system should be guarded against. And I can see that many conventional doctors may be too slow to adopt alternative therapies because they consider them a threat, somehow undermining rather than complementing the system they themselves form part of – but this kind of libel action is not going to make the scientific establishment any more inclined to treat alternative medicine seriously or fairly.

  8. sledpress says:

    I don’t think I’ve ever known personally any chiropractors who would discourage a person from getting evaluated for a possible brain tumor if they had any of the signs that would indicate a brain tumor (headaches aren’t that common a sign really — more likely you’d have seizures out of nowhere, which wouldn’t take you to a chiropractor).

    David is elaborating some points I think are important. it’s fashionable to sniff at “anecdotal” evidence but in a sense, any measures of subjective well-being are anecdotal. Studies of the effectiveness of a medical intervention are designed by doctors, and studies of the effectiveness of chiropractic or acupuncture are… designed by doctors, or at least by people within the mainstream medical paradigm. (There’s nothing funnier than the MDs scrambling for half-baked theories about why acupuncture works when they do find it effective, since they just KNOW without inquiring that the Chinese theory has to be Bunk.)

    When you define what constitutes success, you define who succeeds. And if anyone can demonstrate bias in those cited surveys supposedly showing 50% of people suffering assorted ill effects from chiropractic, a libel suit isn’t that unreasonable. If someone reported feeling dizzy for a few seconds upon getting up from an adjustment, just as you might on getting up quickly from any relaxed prone position, that might go in the “patient felt dizzy” column. How would you know unless you tracked down everyone whose statements were taken for the study and interviewed them, or called the study designers on the stand to elucidate their evaluation criteria? That almost might require legal action.

  9. modestypress says:

    I am not in disagreement with any of the comments posted here. Also, my uncle (who was an engineer at one time) became a chiropractor and professor of chiropracty (living and teaching in Australia at one point) and one of his daugthters became a chiropractor (now practicing in Spain).

    Even though the truth of these controversies is often difficult to determine, the areas of disagreement while infinite are also bounded. We all die of something or other eventually; no one lives forever. A few years ago, I became seriously (and mysteriously) ill and was taken to the local hospital Intensive Care Unit. It was clear to me the doctor who treated me was mostly befuddled by my case and that his treatment consisted of throwing the kitchen sink at me, including steroids, antibiotics, and I don’t remember what else any more. However, within a week my fever went down and I got better. What could be more scientific than that?

    Also I urge everybody to consider the history of what was once known as “childbirth fever,” also known as “puerperal fever.” At one time in history, pregnancy was practically a fatal disease, which demonstrates the stupendous power of sexuality over humans that women still allowed themselves to get pregnant.

    I strongly suggest reading the wikipedia entries on “puerperal fever” and on Ignas Semmelweis, especially if you are likely to get pregnant.

  10. woo says:

    Once again we seem to have strayed from the point I was trying to make, which is that the courts are not the place to evaluate medical efficacy – whether conventional or alternative.

    As I have said, I do not doubt the efficacy of many alternative therapies any more than I doubt the efficacy of many conventional treatments. Equally, I have a healthy amount of skepticism about both alternative and conventional medicine – I don’t blindly trust anyone, no matter what their qualifications, with my health – and I can quite see how scientific tests are only as good as the flawed human beings who design and carry them out.

    All of that notwithstanding, debate should be encouraged, not stifled. Only that way are we likely to make progress in understanding the ways in which our bodies work.

    I doubt the power of sexuality was the only reason why women allowed themselves to get pregnant, despite the dangers of childbirth. I suspect that the fact that women – in many societies and for most of history – were not allowed to work or to own property directly and so had to marry, combined with historically higher sperm counts and the absence of effective birth control measures, meant pregnancy was unavoidable.

  11. sledpress says:

    A court may not be a place to determine the medical validity of one treatment or paradigm over another, but it would be a place to examine whether or not a public representation about one had been supported by citing fraudulent or biased studies — issues like failure to reveal an affiliation, and so on.

    I don’t know the background in this case, but there have been many situations where “debunking” articles and books, to say nothing of research studies, turned out to have been written by people financially entangled with drug manufacturers, agribusiness corporations, and the like. This is the kind of thing I mean:
    http://www.eden.rutgers.edu/~kritee/ACSH.pdf
    You have people who claim to be doing “disinterested reporting” and a little sleuthing reveals there is plenty of handshaking going on behind the scenes. If someone who’d been blasted in print saw a chance of getting a connection like that on legal record, I could hardly blame them.

  12. What an interesting post and series of comments. I think the chiropractors over-reacted in a way that in the long run will make them look bad. But it is a common thing in this society to sue, sue, sue.

    I am interested in the flat statement above that at one time in history pregnancy was a fatal disease. First of all, pregnancy is not a disease. Second of all, if that statement were true, then the fact that the human race has consistently increased its population over the entire history of its existence would be hard to explain.

    I think it is interesting that there are so many very rigorous requirements for scientific “proof” of the efficacy of treatments, including the “standard” of the double blind test. This standard is one of the ones that makes it hard to prove that massage is effective according to the lights of the scientific medical establishment. For the life of me, I have yet to figure out how you would administer a double blind test of massage. Both the recipient and therapist will know whether they have given and received a massage. I think there is a similar problem for chiropractic.

    Interesting side note: TWO of the instructors in the massage school I attended were people who were licensed as chiropractors, had attended the four year program required and practiced as such for over ten years. Both of them had given up the profession in favor of massage, which they both deemed both more effective and safer than chiropractic manipulation.

    In this area about 80% of the chiropractors practice the high velocity thrust technique of adjustment. Only a few of them use the less invasive techniques.

  13. modestypress says:

    I can see I am getting deeper and deeper into deep water here.

    My comments about pregnancy being a fatal disease were intended to be satirical and sardonic. Of course it is not a fatal disease. If you haven’t read the articles I linked to, please take a moment to do so.

    In Semmelweis’ time, it was taken for granted that a large proportion of women would die in childbirth. That was just the way it was, and apparently took it for granted that nothing could be done about it.

    When Semmelweis’ demonstrated that if doctors washed their hands survival rates among mothers skyrocketed. Everyone just ignored him. He was an arrogant and self-righteous man, which did his cause no good, but facts are facts even if they sometimes come from irritating people. Truth (medical and otherwise) is often ambiguous and difficult to sort out–chiropractic is a good example. But sometimes it’s more like a brick across the head.

    • sledpress says:

      Well, the point I take away from the Semmelweis story (and I’ve known it since I was a pup) is that pregnancy was always a bit dangerous, but only when European organized medicine took its management away from the midwives did it become so reliably deadly. The “scientific” medical community of the day, who were highly conversant with centuries of medical writing and spent part of their time cutting up corpses, to the eventual betterment of our knowledge base, took over from the illiterate midwives with their superstitious herbs (most herbal tinctures are at least slightly microbicidal, since plants need defense from diseases) and started ushering germs direct from corpses to women’s birth canals. If they’d stayed out of it, or acknowledged (as Paracelsus did) that there was something to learn from “the sorceresses,” there wouldn’t have been that bump in perinatal mortality.

      It’s still going on. There have been a lot of attempts to de-legitimize doulas, midwives, home birth and even commonsensical practices like leaving the infant with its mother instead of whisking it away to scream in a crib, because those things are untidy and disorderly. Can’t have a doula massaging a woman’s perineum when some doctor can just whip out a scalpel and do an episiotomy. I get fairly frantic if I think too long about this.

  14. woo says:

    sledpress – yep, the danger of ‘special interests’ is certainly one to be avoided. Simon Singh and the Guardian are both entirely independent of any pharma companies or similar though.

    healingmagichands – “For the life of me, I have yet to figure out how you would administer a double blind test of massage. Both the recipient and therapist will know whether they have given and received a massage.” That’s an excellent point, yes. I wonder what the solution would be? Maybe to have one massage performed by someone with training, skills and experience and the other by someone with none (such as me!).

    Very interesting comment about the two chiropractors giving up chiro in favour of massage, too. I have to say, my physio does the most incredible things to my running-battered bod through massage, releasing muscles and tendons which are pulling bones into odd alignments.

    Mr Random – I did understand your point about poor Semmelweis: doomed to be the Cassandra of his day. He and Florence Nightingale seem to have been the only two people on the planet at the time who thought washing anything was a good idea when treating patients!

    And it is worth noting, yes, that todays cranks are sometimes proved to be tomorrow’s medical visionaries… 🙂

    Sledpress – the thing which always horrifies me about previous centuries’ approach to childbirth is the concept of ‘confinement’ which the upper classes seemed to consider so necessary: basically being locked up in one’s room, with no windows open for fear of draughts, for several weeks prior to and after birth, with only one’s mother for company! Nightmare.

    • sledpress says:

      Don’t they still kind of do that when they prescribe bed rest?

      I have read about studies to the effect that bed rest for women in an at-risk pregnancy had little to no effect on the outcome, but I don’t know how large the sample was.

      It seems like whole societies make women’s reproductive functions into an excuse to jerk them around, one way or the other. “You have these mysterious creepy organs, so we get to boss you.” Gaah.

  15. woo says:

    exactly. I have four pregnant friends at the moment and the amount of guilt they are being made to feel for trying to carry on a normal life in the face of the ‘threat’ of swine flu is absurd. I mean, try living in a big city and not being able to use public transport or attend a concert or the cinema for 9 months… its nuts.

  16. sledpress says:

    And flip side, if you have NO intention of ever having children and have the slightest “female trouble,” even now in the 21st century there are doctors who are slavering to whip out your whole crankcase. I could write a book.

    Myself, I would rejoice if the world were bathed in contraceptive rays for the next, oh, at least five years, but I still boggle at the way that the whole world seems to think pregnant women are no longer people with a right to autonomy and boundaries.

  17. sledpress says:

    PS. Vis a vis apparently credible scientific reviews, this just in.
    http://www.nytimes.com/2009/08/05/health/research/05ghost.html?em
    Newly unveiled court documents show that ghostwriters paid by a pharmaceutical company played a major role in producing 26 scientific papers backing the use of hormone replacement therapy in women, suggesting that the level of hidden industry influence on medical literature is broader than previously known.

  18. E F Orwell says:

    The UK Libel Laws have taken another step into the abyss and could signal the end of Free Speech. A UK based media club, The Groucho Club which is owned by a billion pound corporation ‘Graphite Capital’ have launched a one of kind High Court action for a pre publishing test case for libel against Tyrone D Murphy, the author of an exposé book about the club. The book has not been completed yet and the case seems to be based on what could be written and not what has been written.

    The writer is defending this action in person as the costs are astronomical and I am supporting this writer and his cause. All writers and journalists should also support him as he is in the forefront of the battle for free speech.

    What do you make of this type of case where a legal action can be taken against a writer of a book that has not been written yet? This action is certainly a threat against all writers and journalists

    http://www.g-book.co.uk is the book web site

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