A general record of my ongoing battle with all forms of nonsense.

Friday, 23 October 2009

Why making large numbers of complaints about chiropractors was the right thing to do

I've been criticised recently for making large numbers of complaints against chiropractors for making unsubstantiated claims to treat colic. Criticism has come from comments on my blog, from posts and comments on Lanigan's blog, and from the Shadow Minister for Mumbo-Jumbo David Tredinnick MP.

The justification for my complaints is simply that there is no evidence that chiropractic is an effective treatment for infant colic. For the purpose of clarity, I'd like to add that there is also no evidence that chiropractic can help alleviate the symptoms of infant colic.

But some criticism has pointed out that I'm not suggesting an alternative treatment, and while no evidence-based treatment for infant colic exists, it makes sense to use a treatment with no evidence for its effectiveness.

I will now explain why this position is wrong.

What do we mean by "no evidence"? We mean, simply, that there is no sensible reason to believe that a given intervention is effective. There is no evidence that bathing your child in tomato juice is an effective treatment for infant colic. There is no evidence that hanging your child upside down for two hours a day is effective in alleviating the symptoms of infant colic. These might sound like strange things to suggest, but that's my point: there is no evidence base for these being effective. Chiropractic, as an intervention for treating colic, is no different in this respect.

I am aware that chiropractors do use chiropractic as a treatment for colic, but this isn't a reason to suspect it may work.

Some chiropractic colleges teach that chiropractic is effective in treating colic, but this isn't a reason to suspect it may work.

Some chiropractors notice that symptoms of colic appear to subside after chiropractic treatment. But this is equally consistent with the hypothesis that it is ineffective: we know that symptoms subside over time without treatment anyway.

Until there is a valid reason to suspect that chiropractic may be effective in treating colic, chiropractic as a treatment stands equal beside bathing your child in tomato juice and hanging your child upside down.

But chiropractic takes it one stage further. Because despite the fact that there is no evidence to suggest that bathing your child in tomato juice is effective, nobody has ever tried to look for the evidence. With chiropractic, the evidence has been searched for. Double blind trials have been performed. And they have failed to show it is effective.

If there are three hypotheses, all without evidence for them and one where evidence has been looked for but not found, then that one is clearly the least plausible hypothesis.

There are billions and billions of possible things you could do to a small child that might be effective in alleviating the symptoms of infant colic. Only a tiny fraction of them will work. It is completely unreasonable to suggest that any one of those billions of possible treatments may work without some sort of evidence. If you've looked for evidence that one of those billions of treatments works and failed to find it, then it is completely irresponsible to promote it as a treatment - especially, when like most interventions, it is not 100% safe.

With my complaints, I am not trying to deny patients the right to try whatever they want as a treatment. What I am trying to prevent is a group of people profiting by telling their patients that their treatment is effective when there is not only no evidence - but there is actually evidence to the contrary.

54 comments:

Andy said...

And, at the end of the day, the GCC is there to police the industry - how are they supposed to do that if no one complains? It's clear from the number of complaints that have been lodged that they weren't policing it very well before.

I wonder what supporters of chiropractic think would be a legitimate cause for complaint - and how they differentiate such causes?

Silex said...

cause for complaint; BAD chiropractors executing bad forceful manipulation. IMHO all chiro's should update to Torquereleasetechnique.com non force chiro is the way to go with minimal minimal forceful manipulations.

The theory is a sound workable theory. questioning something that the whole planet hardly understands simply does a disservice to us all. understand it first then question it. question the technique and application of the theory.

to quote one chiro upon the correction of subluxation "limitless possibility"

oh and simon....go hang upside down brother...do your neck some good you slimy little toad

Richard said...

Desperate, sleep-deprived new parents will go to great lengths to try to alleviate their baby's colic. I know this because this time last year I was one.

To see such a little child in such obvious pain is horrible, and as a result there's a whole industry out there that thrives on people's desperate desire to alleviate their baby's suffering (and get some sleep!). Unfortunately, so far as I can make out, the only colic treatment that has shown to be effective is a drug the name of which I forget but which reportedly kills or maims roughly 10% of the children that take it, so probably best avoided.

Nothing else out there (and this obviously includes chiropractic) seems to be backed by any robust scientific evidence, but of course desperate people will latch onto anything and there are lots of anecdotal stories of eg. "I gave my baby dillseed oil and after that he got better, therefore dillseed oil cures colic".

Well here's my anecdotal story. Me and my wife sang our baby lots of Flemish kids' songs, and after a great many renditions (or 'provings' as I like to call them), his colic did finally go away. I can particularly recommend "Catootje", a rendition of which can be found here: http://www.youtube.com/watch?v=tfHcjFJ3bAk.

The evidence for the effectiveness of "Catootje" in treating infant colic is pretty much the same as the evidence for chiropractic, except that it's free, and you can find it on youtube. Enjoy!

Jackie W said...

In my local area I have GP’s and physios manipulating spines, osteopaths treating colic and learning difficulties and I recently heard a physio talking about treating autism. All of these treatments would appear to be at odds with your paradigm but you seem to have a specific issue with chiropractic. Is there a particular reason for that - beyond the BCA / Simon Singh libel case? It appears to be at odds with a public interest agenda to be so exclusive in this way.

( Silex - WTF ??! )

Silex said...

hahaha. YEAH MAN!. sing to em!, nurture em, fix dem subluxations. simple. do what you do with a good coating of love and you cant go wrong.
Add some raw food, super food nutrition, cranio sacral therapy and for a healthy dose of good measure..feed em some ayahuasca. there we go thats a whole paradigm of healing that'l keep you quack skeptics busy for years to come with confused muggs

uh..jackie. please explain further what you mean by' at odds with my paradigm'.

all those wonderful healers tackling the problem. good on em. better than us fools sitting here writing about stopping em.

I think i've outlined WTF? rather nicely

Silex said...

I have a specific issue with ignorant fools running a smear campaign about a topic they have no understanding of, offering no service of value to the community, and slowing down the evolution of healing the human race.

Simon said...

@Jackie W

If you look back at previous entries in my blog, you'll see I've covered a number of issues such as allergy tests, claims of Traditional Chinese Medicine, psychics, a local library lending books with dangerous health information, magnetic therapy and more. I've reported a lot of these things to trading standards and the ASA.

There is not sufficient time to expose every single form of nonsense, but I am concerned about some of the issues you raise.

Chiropractic did get my initial attention because of the BCA's action against Simon Singh. However, the index on the BCA's web site and the GCC made it possible to get hundreds of chiropractors to stop making claims with the effort it would normally take to change 30 or so. So one important factor is that I can be more productive if I focus on one issue.

A second factor is that chiropractic is meant to be regulated. This gives it a sense of respectability which it would deserve if the regulator actually regulated. Instead, the regulator acted to defend the woo.

Silex said...

simon has run away.....to his little corner....where its all safe...he didnt have anyone singing to him when he was young. neither did I brother. I sing to you now. My song however has got some distortion, with some delay on those lead guitar lines. and my lyrics say one thing. WAKE UP!!!!!!!!!!!!

Silex said...

he's back!!!!!!! yeah all those other things you dont understand that needed addressing hey? you speak nonsense to me my man. err.. thats non-sense. is that what you come back to me with? write some more lines. more lines my man. cause that wont suffice. focus on this...and go read up on some chiropractic before you join the army of ignorance and stupidity so willingly.

Warhelmet said...

"Someone in wrong on teh internets" works for me! ;)

Silex said...

RESPECT!?? haha. your conversation with that chiropractor showed no respect. only ignorance. for you to question the concept of subluxation so openly displaying not an once of knowledge of it is disgusting. who are not helping at all! IF you wanted to help, there are so many avenues you can do this. spin in a circle and start walking...you'll find somewhere that needs help.

Richard said...

Silex,

I'm very disappointed by your narrow-minded dismissal of my patent 'vlaamskindjelied' (VKL) treatment for infant colic. I don't need fancy terms like 'sublaxtion' to know what I saw, and I saw with my own eyes that VKL works. In fact, I believe we need to be open to the possibility that VKL could also help with other ailments too. It's a known fact that Flemish kids are all-round much healthier and happier than their British counterparts. Can this really be a coincidence? Or are you too afraid to have your preconceptions challenged here? Which is it, Silex?

Chris (from Oz) said...

In fact we could say that bathing your child in tomato juice has MORE evidence to support it's efficacy than does chiropractic.

Afterall, it has about zero evidence.
Chiropractic has negative lots.

Jackie W said...

Thanks Simon -

All fair points. I have had a look back through some of the previous posts on various random healing arts & yeah - any claims of panacea in any context are clearly bollocks.

I can see how the BCA action has provoked the ire of many bloggers etc & the GCC has been caught w/ it's pants down. I also understand that the mechanics of the websites etc has made it all easier to do - as has the fact that the GCC & the BCA are herding chiropractic cats.

I do have a an issue w/ how RCT's are used in this context though.

I agree w/ the analysis that essentially, manual treatments in any setting are often applied to conditions for which the pathoanatomy is poorly understood or has a weak or inconsistent correlation with clinical findings. Imaging can be misleading and standard orthopaedic testing can be unreliable.

An RCT investigating a headline condition can find a particular treatment to be ineffective for a study population yet that treatment may be very effective for a specific as yet undefined subgroup. So – the therapeutic baby gets thrown out with the statistical bath water.

It just seems like such a blunt tool, when mindful clinical practice in manual therapy relies on clinical reasoning & clinical reasoning involves more than RCT’s.

I’m not defending osteopaths treating colic, physios treating autism, GPs doing acupuncture & I’m not defending subluxations either. All I'm saying is that, when it comes to RCT's in clinical practice - it's a bit more complicated than that..!


Silex - STAY OFF THE CRACK..!

Silex said...

bit more complicated than that? haha. nonono simplicity is beauty. And richard. explain to me more about your healing methods my man, i don't understand what you mean by your terms. enlighten me. but from what i understood, you sang to your infant and healed it. thats beauty my man. narrow minded? hmmmm dont understand. have had reports of similar healings from my sound concerts. i am delighted by every one of them. i didnt even need to touch them, yet i managed to touch with a word and some sound. health is simple. people want to make it very complicated and you have to go through much complexity to get to the simplicity this much is true. thats why im upset, cause people dont want to take the trouble to read, understand, explore and be curious and simply delight in tearing down each others ways of doing. crack? haha magical medicine my dear. you should find some. a cup of tea would be a good start.

Blue Wode said...

Great post, Simon - not that you needed to justify your actions.

Readers might also be interested in what the National Council Against Health Fraud had to say about a recent systematic review of adverse events associated with chiropractic care of children:

Quote:
"A systematic review has identified 34 cases in which spinal manipulation in children was associated with adverse events. [Vohra S. Adverse events associated with pediatric spinal manipulation: A systematic review. Pediatrics 119(1) January 2007, pp. e275-e283] Fourteen of the cases involved "direct" events in which the treatment was followed by death, serious injury, symptoms requiring medical attention, or soreness. The rest involved "indirect" events in which appropriate diagnosis was delayed and/or inappropriate manipulation was done for serious medical conditions such as meningitis. The reviewers commented that despite the fact that spinal manipulation is widely used on children, paediatric safety data are virtually nonexistent. This type of review cannot determine how often adverse events occur. That would require a prospective study with active surveillance. The article did not consider harmful aspects of chiropractic care that are far more common than the reported events. These include (a) decreased use of immunization 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."

http://www.ncahf.org/digest07/07-14.html

In view of the above, especially when one factors in points (a), (b), (c), and (d), it is apparent that a risk/benefit assessment for chiropractic as an intervention for colic can only be unfavourable. Unfortunately, however, any chiropractor who arrives at that (responsible) conclusion is almost certain to find that it works against his or her financial interests.

Silex said...

yay!!! intelligence abounds. some real crit of bad chiropractic. forceful manipulations of spines is old school crap. find a chiro thats on top of the game and he is in depth into non force and neurological based chiropractic.

Bad chiro. crit the technique, not the discipline.chiro at least sees a unique problem. the techniques however are suspect abound. the modality is only as good as the practitioner. this is true my friend. choose wisely. look in the eyes of your chiro or who ever is offering treatment and ask yourself. can i trust this person?

Silex said...

But simon my man. dont mind me to much, I really am a hearty jolly feller in person. a hug and a breath does wonders. if we ever meet in person. jolly smiles all the way. perhaps you could enlighten me more about this software in my computer, since if you guys really want to see a confused mug, its mine, working out how to get music out of this thing. respect all the way brother. but wake up, is all my message is. i do feel however that a good response to my comments would be a good show of integrity., since you have completely avoided it. no need in justifying actions that have already taken place, but some further enlightenment and conversation...to update yourself in light of severe crit would make you a little less of a slimy toad and more of man huma being with purpose. hit me with it brother. im all eyes :-)

Jackie W said...

Silex - really - stay off the crack.

Anonymous said...

when you are done with chiropractors perhaps you should deal with the HPV vaccines that have no proven benifit.

Simon said...

@anonymous.

Would it really have been difficult for you to spend 30 seconds on pubmed before spouting this dangerous nonsense on a public forum?

http://www.ncbi.nlm.nih.gov/pubmed/19823051?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/pubmed/19684472?ordinalpos=8&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

Silex said...

vaccines. yeah simon...go after those. i know you dont understand it cause you probably havnt read a damn thing about them, but yeah. do it, cause thats some screwed thinking right there.

and jackie, WTF? you stupid cow. you write like your stuck in a never ending excell spreadsheet you beingless fool. i didnt give you any cause for such stupid allegations other than passionate intelligent expression backed with knowledge of the topic at hand. your obviously just someones little secretary.

how many people have you helped today?

crack...haha...the only crack im on is my buttox, sitting up mighty finely straight on this chair right here....free of subluxations, and my organs , my brain included, working at optimum level.

how many stupid people in the world are there jackie. Why do you join them? since i do see intelligence lurking in you. Whats your problem?

outline it for me without those stupid one liner comebacks, or have you forgotten how to have conversations with people from all that time sitting staring at a computer?

Silex said...

"could it really have been difficult for you to spend 30 seconds on pubmed before spouting this dangerous nonsense on a public forum?"

holy shit simon. are you blind my man. I hold up the mirror to you right now my man.

would it really have been difficult for you to spend 30 seconds on pubmed before spouting this dangerous nonsense on a public forum? or actually go the library and read some other academic journals?

you said it yourself my man. Go and do it!!!!!!!!

Silex said...

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

By just repeating the nonsense you've been told without checking it, you're a menace to public health.

Jackie W said...

@ Blue wode

In the context of this discussion, that is a very strange comment.

Of course mass complaints need to be justified. It is of major consequence to the individuals involved and justifying actions is what this is all about.

@ Silex

Help is out there x

Silex said...

Guerilla Chiropractic: How to Survive in Today's Hostile Environment (Kindle Edition)

heehee. look at what these guys gota write about to stay alive cause of fools like you all.

"Starting and maintaining a chiropractic business is not easy these days. Managed care, high insurance deductibles, the fractured nature of the chiropractic profession, and monthly onslaughts from anti-chiropractic groups stand as barriers to success. "

hohoho. barriers to healing more like it, but yeah, success to

JACKIE!

Silex said...

more one liners! haha stupid wench. i know help is out there. cause im one em helping unlike you fools

Silex said...

silence speak loader than words i guess.

fucking bunch of ignorant stupid fools. every last one of ya.

one day this sorry fact will hit you between the eyes and you'll cry like little children for months.

then youll wake up and be human

Silex said...

how the hell can you people crit what you have no understanding of? but you peopl are small fry. there much bigger badder ignorant foold out than you folk. check out quackwatch.com. youll find some ignorant stupidity on chiropractic and a whole host of other things right there, but at least he's a medic with knowledge of medicine being a dumb as, unlike you people who simply dumb asses.

hunting quack hunters and gate crashing the party. yippee

to Barret. MD

ear sir.

I had a look through your site and had to send this very small
comment. Mostly in connection to your thoughts chiropractic and cranio
sacral therapy.

My friend, the only thing I can do is laugh. I do not laugh with you,
I laugh at you. It is so blatantly clear that you, my friend, are so
far off the mark of progress that a fit of giggles is the only way to
respond.

Ignorance and Stupidity. These are the two words that sum up so much
of what I read on your site.

What a fool you so blatantly advertise yourself to be. I look forward
to responding to every single article and outlining the extent of
this. What a useless waste of time, but wow, it seems so necessary
since people like yourself, intelligent people, just cant see the
obvious and do such a disservice to humanity in the process.

What is it with the medical world and feeling threatened by new
approaches. Conversation and fueled growth together, Is that not the
way of science? No, lets just rather tear down what we don't
understand. Fear, thats the root of it.

or rather..as a one liner (for jackie) "a self appointed vigilante for the suppression of curiosity." this fool is.

you fools are small fry. pawn in the army of ignorance and stupidty.

Silex said...

ok guys. i think my job in this nest here is done. i'm sure you will all be happy that i leave you to your comfy lair of stupidity.

but before i leave. I must at least sing a song to you, to contrast my spoken word. find your own harmony

Endangered species, caged in fright,
Shot in cold blood, no chance to fight.
The stage is set, now pay the price.
An ego boost, dont think twice.
Technology, the battles unfair,
You pull the hammer without a care.
Squeeze the trigger that makes you man,
Pseudo-safari, the hunt is canned...
The hunt is canned.

All are gone, all but one.
No contest, nowhere to run.
No more left, only one.
This is it, this is the countdown to extinction.
Tell the truth, you wouldnt dare.
The skin and trophy, oh so rare.
Silence speaks louder than words.
Ignore the guilt, and take your turn.
Liars anagram is lairs,
Man you were never even there.
Killed a few feet from the cages,
Point blank, youre so courageous...
So courageous.

One hour from now,
Another species of life form
Will disappear off the face of the planet
Forever...and the rate is accelerating.

I just oh so wish it was you slimy life forms that this song was about.

ho ho and and merry fuck you

Silex said...

Other simon at least had the decency to respond-

Many thanks for your deeply insightful email. Unfortunately, I am currenly busy fighting the legal case, so I don't have time to respond in any detail, but I am sure that you will find lots about my views on various websites.

Thanks again for such a thoughtful contribution to the debate.

Best Wishes,
Simon.

Ps. I will try to slouch less. Thank

If one good thing could come from this....its less slouching. Good on you simon.

"Ps. I will try to slouch less. Thanks." Well if one thing good comes from this my friend, I'd be grateful for this. But grateful am I that you took the time to respond, this is more than i can say for many others.

You speak to a man who has been in pain, tension and trauma for many years on many fronts battling a diseased spine and had to self learn chiro techniques to sort it out. ever done self manipulation? thats chiropractic for ya. Once you discover that and slowly find that upon correction of vertebrae, that your stomach is able to take in nutrients-those super foods doing nothing before having solved the neural compromise-your brain actually starts computing thoughts again, your heart starts doing its job properly, and slowly you claw your way out of the depths of fatigue. You will know my friend. You would know.

Lots of bad chiro's out there. Tell them to all update to non force neurological approach
like www.torquerelease.com. Forced manipulation is old school. You gota love those Subluxations straight. Release tension and release compression and the subluxations glide back into place. Gently, easily, no harm done

Go after all those bad chiro's doing bad forceful manipulations, cause no good comes from that, your right, no evidence. And get funds for lots of research. throw funds at em to sort themselves out so that they don't need to be sneaky.

Just please my man, don't tear down a whole discipline in the name of fear and ignorance. Chiropractic is the only discipline that woke up to look at the spine and be intrigued. Before then, we were all ignorant and stupid. They need help, not more slander.

Don't throw the baby out with the bath water.

Respect

Jackie W said...

Silex - come on now - I thought you said you were leaving?

You seem to have developed a monologue & the idea of this type of platform is dialogue. You made your point and I have the feeling by now you might be shouting randomly at an empty space.

I'd really like to hear back from some other people on the topics raised but it seems you're mostly just being gobby & rude, & as a result, ruining any constructive conversation.

By addressing this to you, I really don't mean for you to come back to me on this. In fact please don't -(please don't!)- I get the picture..!

Blue Wode said...

@ Jackie W

I’m not quite sure what you’re getting at. If the individuals involved in the mass complaints are confident that they have not breached any of the requirements set out in their Code of Practice, then what is there for them to worry about? On the other hand, if they suspect that they have contravened their Code of Practice, then the consequences of that are deserved.

Silex said...

*puff of smoke*

Jackie W said...

@ Blue Wode

That distinctly Orwellian rationale could be used to justify complaints against any profession w/ a regulatory body - a complaint that may be better directed at the regulatory body itself perhaps. If I were to make a mass complaint against anyone I would make sure I could justify it – for myself and to be fair to those I was complaining against.

I think Simon is being fair by outlining his reasons & that’s what I’m getting at - fairness.

Blue Wode said...

@ Jackie W

Thank you for your reply. IMO, Simon's reasons for making the mass complaints were perfectly obvious without having to spell them out. However, I appreciate now that his post has been worthwhile for some.

Silex said...

'That empty space being the chasm between your ears'.........echoes in the stadium in the wake of my deature

Anonymous said...

Hi Simon,

This is not a criticism, per se - more a question. Where you say that

"If there are three hypotheses, all without evidence for them and one where evidence has been looked for but not found, then that one is clearly the least plausible hypothesis."

If you are testing the null hypothesis, then surely a null hypothesis that hasn't been rejected has the same intrinsic value as one that hasn't been tested. It's quite possible that I'm wrong here, so please do say if I'm barking up the wrong tree. (I've learned a lot from blogs such as yours, so that is why I query this.)

In the case of infantile colic, I think we should ask, now why would chiropractic work? From my understanding of the way the human body works, I would have to say there is no reason why it would work.

Keep up the good work with those complaints! My feeling is that it's the right thing to do if you have a social conscience.

Cheers,

Andrew

Simon said...

Hi Andrew,

Interesting question. I think the point I was making was that if you randomly make up three ideas without any kind of reasoning, they are equally unlikely to be true.

If there is one that has been shown to be false with testing, this is even more unlikely to be true.

However, the null hypothesis is slightly different.

The key point is this: Most things don't work. For every one action that will make your car's engine start, I could name a billion other actions that wouldn't (please don't ask me to).

So because I can name a billion things that don't work for every one thing you can name that does, it makes sense to go with the null hypothesis until the evidence is in.

That's not to say that you claim "X doesn't work". It's moreover that you claim "X has not yet been shown to work. I'll be open-minded, but assume for now that it doesn't work until you come up with some evidence".

Simon

Cosmic Navel Lint said...

Simon,

all the best in this needful cause. Good luck to both you and Simon Singh in your endeavours!

Jackie W said...

Hi Simon

Way back on 23 Oct (11.06) I made some points about the use of RCT's in clinical practice. That was originally one of the questions I wanted to ask you and since then, I seem to have been swept along with the mele. Perhaps it was my fault for not framing the comments specifically as a question.

So, with reference to the post on 23 Oct, should mindful clinical practice rely exclusively on RCT's?

I would be interested to hear your thoughts on that point before the mele moves on.

Thanks

Jackie

Simon said...

Jackie W,

Sorry I missed your Q previously.

I think there are cases where we can rely on other evidence. If a disease that shows little history of clearing up by itself suddenly clears up in a good percentage of people after they receive a treatment then we can probably place a certain degree of trust in those case studies, so long as the case studies were tracked from the beginning and not cherry-picked after the disease cleared up.

That’s not the case with the chiropractic/colic case studies though. Colic is something that clears up by itself. Case studies that show colic clears up after chiropractic treatment is, well, bloody useless.

Cheers,

Simon.

Jackie W said...

Hi Simon

I confess I have very little experience in paediatrics so I don’t really feel in a position to comment on that specific situation but I definitely see your point on the limited use of case studies. However, I still have this nagging doubt that your analysis doesn’t take into account the full gamut of information used in a clinical encounter.

Speaking as someone who works well within the definition of evidence based manual therapy, I am on the front line of making clinical decisions but would find it nigh on impossible to rely purely on RCT’s.

Many clinical diagnoses are still based on ‘sprains’, ‘strains’ and ‘syndromes’ for which definable absolutes are impossible to establish. The variables involved with individual cases presenting for manual therapy are enormous – even within the same category of diagnosis. The vast array of variation in the individuals presenting & the specific training and direction of the manual therapist themselves, renders a purely statistical analysis fragile when making clinical decisions on the ground.

As you quite rightly pointed out, case studies are similarly limited, so in-between there has to be skill, judgement and interpretation - all based on the best information available. Unfortunately, the lack of absolutes dictates that judgement has to play its’ part. The results of many standard orthopaedic tests (and even advanced imaging procedures) also need to be processed and interpreted with care and once you add in judgement and interpretation, pure statistical analysis gets really shaky.

Until more clearly definable absolutes are available in manual therapy, the practical reality is that clinical practice has to be more than RCT’s. They are vital and useful yes – but slavish reliance assumes way too much of current knowledge and seems to ignore the subtleties of real world clinical encounters.

Do you agree that this lack of absolutes in manual therapy limits the clinical application of RCT’s?

Again, that’s just my 2p & I’m curious to hear your thoughts…

Thanks

Jackie

Jackie W said...

Hi Simon

It's been nearly a week now - any view on the RCT question..?

Thanks

Jackie

Simon said...

@Jackie W,

Sorry Jackie. I had actually started composing a reply and then was not 100% sure of its relevance. I started again and never finished.

Quick question to help me out: Can you give me an example of a treatment that you would give without RCT, tell me what you'd give the treatment for and also what evidence you do have that it works.

Might be easier to work with a specific example.

Jackie W said...

Great question - I'll get back to you with a specific example tomorrow..!

I would say though, that it will only be a single example from just one of the grey areas in manual therapy and I suppose I'm asking about the broader principles here ie: the possibility that in manual therapy, RCT's alone are incapable of reliably quantifying the entirety of a patient encounter.

These types of questions have been a point of conflict between 'scientist' & 'clinician' for many years so this current situation is not new or confined to a single profession.

Interestingly, the need to bring the question to a single example is an example of making a problem solving situation easier by giving it clearly defined parameters...

KR

Jackie

Jackie W said...

Hi Simon –

Sorry it’s taken a few days to get back to you.

I’ve actually come up w/ 3 examples – one with a lack of evidence, one with conflicting evidence and one where the quantitative findings raise more questions than answers.

Manual Massage is one of the most widely used treatments in Manual therapy – it’s popular with therapists and patients. Galloway & Watt (2004) found that up to 52% of treatment time was spent on massage for athletes at major sporting events. However, empirical evidence for the efficacy of massage is weak and there is very little RCT evidence for all the theoretical physiological benefits, which are often claimed. So – will I stop all soft tissue work in my treatments until there is an RCT that says it works? Personally, no - I have to use clinical reasoning, judgment and experience.

An example of conflicting evidence is in giving exercise in cases of acute low back pain. Giving exercise actually goes contrary to the findings of the Cochrane Collaboration Back Review Group (2000), which stated that:

“Specific exercises are not recommended for acute lower back pain patients…”

Waddell (1996) said much the same sort of thing. On the other hand there are also studies that show exercise prescription in acute low back pain to be effective – notably into the Mackenzie protocols, but also through the work of McGill, Liebenson and others.

So there is the thing – the evidence directly conflicts so is impossible to follow. In any given acute low back pain case, I unavoidably ignore at least one set of RCT results depending on whether or not I choose to give an exercise. When someone presents with acute low back pain, I have to make a judgement on the likelihood of an exercise being beneficial for his or her specific situation based on other case-specific variables. Again it comes back to the awareness of RCT’s along with clinical reasoning.

Finally - the use of MRI & CT in the diagnosis of disc herniations and nerve root pain (‘Sciatica’). Simple you might think – disc bulges, hits the sciatic nerve & off goes the pain down the course of the nerve– take an MRI or a CT & there it is. However, false positive rates can be as high as 50% - ie the same disc lesions seen on MRI or CT are also present in asymptomatic individuals (Boden 1990, Brandt-Zwadzki 1994 & 1995, + others). That undermines the certainty and clinical relevance of that imaging procedure in that particular context, which in turn reduces the amount of definite information available to make absolute clinical decisions. It also questions what we thought we knew about disc lesions if they are present in so much of the asymptomatic population.

As you can see, it all gets very messy indeed, but I hope that helps clarify the question..!

Looking forward to hearing your thoughts on this.

KR

Jackie

Simon said...

@Jackie W.

I haven't looked into the evidence for anything that you've told me, this reply is based solely on what you've said.

Well, my opinion for (i) is that if there is no evidence for efficacy, it would be immoral to sell the service.

For (ii), if the evidence is mixed then I don't think you should be selling the service until the evidence is in. Especially if a Cochrane Review of the evidence recommends against it.

For (iii) I think I would need to do a lot more research (which I don't have time for at the mo) to properly answer the question.

Jackie W said...

Hi Simon

Thanks for taking the examples at face value – I have given them in good faith. The ones I have given are all pretty standard stuff but I appreciate that this is a huge area & very difficult to get to grips w/ all the research.

I didn’t want to get too bogged down in the examples though – they were purely meant to be illustrations of potential pitfalls in the practical application of the evidence, rather than questions in themselves.

I’m really driving at a broader key principle here so I’ll try & frame the original question in a slightly different way –

Can clinical decision making in manual therapy be based exclusively on RCT’s?

That’s about as clear as I can make it..!

KR

Jackie

Simon said...

@Jackie W

Can it? Depends.

Well I think I replied to that in my first response:

"I think there are cases where we can rely on other evidence. If a disease that shows little history of clearing up by itself suddenly clears up in a good percentage of people after they receive a treatment then we can probably place a certain degree of trust in those case studies, so long as the case studies were tracked from the beginning and not cherry-picked after the disease cleared up."

So does this apply to manual therapy? Probably not. If you're treating things that sometimes clear up by themselves, an RCT is required.

Jackie W said...

Hi Simon

You’re right - RCT’s are not the only evidence used to make clinical decisions. It isn’t a case of using RCT’s, or case studies, or that’s it.

Your answer doesn’t really square with your previous comments about the examples I gave though.

If you’re saying that RCT’s are ‘probably not’ exclusively applicable for decision making in a manual therapy, then how can you classify the use of massage as part of a treatment, (or choosing between RCT’s of equal quality for the use of exercises in acute LBP), as immoral?

Is it immoral enough for you feel justified in making a complaint against me for using soft tissue work or Mackenzie exercises as part of my management?

I think I should also point out that a huge number of conditions presenting to medical practices & to manual therapy clinics of all descriptions will have a favourable natural history ie: will get better by themselves over time. Some conditions presenting to A&E will clear up by themselves. The ubiquitous nature of conditions with a ‘favourable’ natural history means that the simple presence or absence of eventual recovery cannot always be used as the final arbiter for the application of treatment.

KR

Jackie

Jackie W said...

Hi Simon

...exclusive use of RCT's..??

...immoral treatments..??

...self limiting conditions..??

The value you place on RCT's underpins your case but you appear not to know how or when they are applied in real world clinical situations.

I posted these questions 4 times over the course of a week before they even appeared on the blog & I still have heard nothing back from you.

It looks as if I had been congratulating you on a job well done, my post would have appeared more promptly. Perhaps the GCC aren’t the only ones acting as if they have something to hide..?

KR

Jackie

Simon said...

@Jackie

>..taking a week
Actually, I saw several posts identical comments from you come in at once. Thought I'd published one but hadn't, then saw the new ones and didn't know why you were resending them all the time. Then I finally figured out that I hadn't published the first one, sorry.

>Delay
I've been incredibly busy.

>Ethical
Your comment said that "empirical evidence for the efficacy of massage is weak". If this is the case, I stand by the statement that it is therefore unethical to sell this service to an uninformed consumer.

I stand by the statement that depending on the circumstances, the evidence does not necessarily need to come from RCTs. As an extreme example, if you found a drug that made an amputated leg grow back, I'd be happy with a small number of case studies. At the other end of the spectrum, you definitely need RCTs if you're dealing with a treatment for a short term self-limiting disease.

I don't know how much this relates to the specific treatments you are promoting as I have not looked into the specifics.

Jackie W said...

Hi Simon

Well done - I thought I might get a quicker response to that post! (Of course, apology accepted)

So. Leg replacement drugs. OK. Not worried about, long term side effects, anything like that? I seem to remember something about Thalidamide in your ‘the health of the world depends on it’ letter. An extreme-ly bad example.

Interestingly, you seem to be saying that there is a spectrum of conditions for which clinical certainty is variable and the application of RCT’s not always definitive.

The question then is how does that spectrum look? What conditions are on it? Where are they on it? Who decides that? Should it be in categories of diagnosis or individual cases? What exactly is short term - 1 week? 12 weeks? 1 year? What is self limiting – 100% resolution? 50%? How long is it acceptable for recovery to take? Who decides that? What if it’s severe but self limiting? What is severe? Who quantifies severity? Who decides when to treat? How to treat? Who decides?

I know - I’ll ask the ASA.

The problem is that you don’t really know what circumstances evidence other than RCTs might be used, what that evidence might be, or indeed, how it might be applied in practice. That’s fine – it’s an enormously complex area that you clearly (hopefully) don’t work in. However, even though you seem to have a weak understanding of the basic principles of clinical reasoning, you still feel justified in questioning my ethics regarding my rationale for the use of massage.

‘Sense about Science’ is great. Fantastic. What you seem to be flying a flag for is ‘Sense about Statistics’ – which is nonsense. The final outcome of such a campaign would be clinicians engaged in recipe management – unwavering adherence to statistically based protocols. In practice, clinical reasoning is not just judgement of facts, it is a judgement of values, attitudes and expectations as well. Either you have a poor understanding of this concept or you’re making a deliberate effort to ignore it because it doesn’t fit with your basic model.

KR

Jackie