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

Wednesday 12 August 2009

Will Trading Standards now take on the General Chiropractic Council?

Sometimes the Trading Standards bodies I’ve written to get in touch with the GCC for more information. And, thanks to a trading standards officer in the Highlands, the GCC’s response is on the trading standard internal database. An officer in London who had received one of my complaints got in touch to ask about the evidence in their response.

I am extremely grateful that he did.

The GCC has been issuing a letter to Trading Standards officers considering action against Chiropractor practices. The letter appears to be deliberately designed to confuse trading standards officers and misrepresent the evidence – and it has managed to do that to great effect.

The text of this letter is available on DC Science blog.

Firstly, they include the text from their patient information leaflet:

Chiropractors mainly treat
  • back, neck and shoulder problems
  • joint, posture and muscle problems
  • leg pain and sciatica
  • sports injuries

You may also see an improvement in some types of
  • asthma
  • headaches, including migraine; and
  • infant colic
So firstly there is some confusion here. If an improvement can be the result of chiropractic care, then why don’t they use it as a treatment?

“It is important to emphasise that the GCC doesn’t claim that chiropractors 'treat' asthma, headaches (including migraine) and infant colic. It is possible that chiropractic care may help to alleviate the symptoms of some of these conditions.”

What are they talking about? If chiropractic care can help to alleviate the symptoms, then it can be used as a treatment. The evidence throughout the asthma trials that they quote is clear: wherever the trials are properly blinded, it shows the treatment to be useless. I’ve been through the trials they’ve referenced for asthma: Brønfort in 1997 (note: I have not managed to find this paper – but the GCC’s letter acknowledges that this paper concludes that the treatment is ineffective), Brønfort et al 2001, Nielsen NH, Brønfort G, Bendix T. et al 1995 and Balon J, Aker PD et al 1998.

All these papers reach the same conclusion: the SMT (Spinal Manipulation Therapy) is ineffective in the treatment of asthma.

So what are they talking about when they say “You may also see an improvement”? Well the key word, I think, is “see”. While the trials they listed all reached the unanimous conclusion that SMT is ineffective in the treatment of asthma, Brønfort et al, 2001 (a pilot RCT) also found that the patients reported that their life had got better. But the paper did not compare this patient-rated outcome measure between SMT and control group. And the paper even states that “observed improvements are unlikely as a result of the specific effects of chiropractic SMT alone”.

So perhaps what they mean is that if you get chiropractic treatment for asthma, then you might think it did some good, however:
  • Objective measures will show that you haven’t been helped, and
  • You would have thought you’d been helped if you’d undergone a sham procedure too, and
  • This information came from a pilot study and is therefore not particularly reliable.

When the GCC lists this paper as evidence, they only mention that “the children rated their quality of life substantially higher and their asthma severity substantially lower.” The GCC completely neglected to mention that this study concluded that SMT is ineffective in the treatment of asthma.

They then go on to list 3 more papers that they say “appear to echo the evidence levels outlined in the paragraphs above”:

a. Nielsen NH, Brønfort G, Bendix T. et al 1995. Chronic asthma and chiropractic spinal manipulation: a randomized clinical trial. Clin Exp Allergy Jan;25(1):80-8
b. Balon J, Aker PD et al 1998. A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma. NEJM 339 (15): 1013-1020
c. Brønfort G , Evans RL, Kubic P, Filkin P 2001. Chronic pediatric asthma and chiropractic spinal manipulation: a prospective clinical series and randomized pilot study. JMPT 24(6):369-77

But they fail to give any further information about these trials. Why? Why have they not quoted the conclusions, or sent the trial papers on along with their letter?

Why has the GCC not clearly stated that all of these papers conclude SMT to be ineffective in the treatment of asthma?

Why did the GCC list 4 papers that all concluded that SMT is ineffective in the treatment of asthma – but still state “although some clinical trials had positive results there is insufficient data to make strong statements about efficacy”?

Why has the GCC failed to reference the largest and best reported study of the use of SMT in treating infant colic?

How would the General Medical Council react if our GPs started advertising that they were willing to provide ineffective treatments for asthma?

Would they jump to the defence of those GPs?

Would they write letters deliberately designed to confuse Trading Standards?

Would they wait for a member of the public to issue a specific complaint about a specific practitioner before taking any action?

Would they publicise on their web site that “you may also see an improvement” if this ineffective treatment is used?

I think not.

The GCC is meant to be the body designed to regulate the chiropractic profession. With its actions, it has proven itself not only utterly incompetent, but it is actually protecting the very actions it should be regulating against.

The Trading Standards officer I spoke to yesterday was very much of the opinion that Trading Standards should be tackling the General Chiropractic Council directly. I am not sure if this is within their remit, but personally I am now shifting my focus in this direction.


Matt Lodder said...

Oh, so they don't "treat", they just "alleviate symptoms"! Anyone understand the difference?

Le Canard Noir said...

The new Trading Standard laws are very unsympathetic to such weasely worded nonsense. There is an 'average man' test which looks at how what different actions a consumer would take given the message. Since, just about everyone may not appreciate the subtleties in these weasel words we can be pretty sure that your average person would believe a chiropractor was offering to treat (successfully).

John Edmondson said...

I think that it is not only important that all alternative medicine practitioners state their evidence but that they make it clear as to their limitations. There are a lot of people who are very skilled at massage, manipulation and so on but at the same time the dangers must be recognised. Manipulating a spine that had a carcinomatous secondary in it could cause it to collapse and do serious damage. I think it is time that there is proper accountability for these treatements.

Crispian Jago said...

Being unable to suitably articulate my own words, I have resorted to modifying some Python again:

Andy said...

It is also a fact that if I dance naked in the town square singing Celine Dion songs, you may see an improvement in your child's asthma. Though I don't promote it as a "treatment".

Similarly, if you give me your car and pay for my next holiday in Amsterdam, you may see an improvement in your baby's colic. Again, it's important to emphasise that I don't claim to treat colic.

I wonder if their members do claim to charge for the non-treatments for ailments that they don't claim to have any treatment for but which might accidentally seem better after you've paid that bill?

SkepticBarista said...

They don't claim to 'treat' colic ....Well perhaps the GCC will contact this chiro and offer them some advice:


"Children have also been successfully treated by chiropractors for asthma, breathing difficulties, sleep problems, feeding problems, colic, hyperactivity, bedwetting and much more"

That certainly looks like a 'treatment' claim rather than a 'may help' statement !

I have a sneaky feeling TS will be looking at this one ;-)

Andy said...

Prompted by still more weasel words coming out, I finally got my "weasel words" article up here.

J Saeks said...

The reason the do not say they treat asthma is because they would be brought up on charges of practicing medicine without a license. The reason chiropractors comment on alleviating symptoms of asthma is 2 fold, 1 many patients report to their Chiropractor a reduction in onset and severity of asthma attacks with chiropractic treatment. Secondly if the chiropractor is doing muscle work on the intercostal muscles and the diaphragm (2 muscles used during asthma attacks) there may be a reduction in post attack symptoms.
The reality of a blind study using Chiropractic is that it is impossible, in much the same way no surgery has randomized controlled studies yet it is done all the time without the mention of the number of cases of people dying as a result or drug companies not reporting the number of deaths due to their product. Look up the death rate of people yearly from NSAIDs. Chiropractic is a very valuable modality that helps many people yearly and stresses Prevention not just to give someone medicine(with all it potentially deadly side effects) and hope it helps. That is not to say there are not Chiropractors out there who are unscrupulous the same as Medical Doctors!

Simon said...

@J Saeks

>many patients report to their Chiropractor a reduction in onset and severity of asthma attacks with chiropractic treatment.

Probably true, but patients are well known to report success on treatments that don't work. Look at the reported success of homeopathy.

>The reality of a blind study using Chiropractic is that it is impossible

Brontfort 2001 (see link above) tested to see if it was feasible and concluded that it was. 64% of people in sham group guessed they were having real SMT and 73% in the treatment group.

>Chiropractic is a very valuable modality that helps many people yearly

You can only know that by conducting trials. The trials say it doesn't work for asthma. I'm not attacking the profession as a whole. The profession is bringing itself into disrepute however by advertising its services for issues that it has been proven incapable of helping.

>medicine(with all it potentially deadly side effects)

Chiro has its share of deaths, and also regularly uses x-rays without them being required - especially in the USA.