Simon Singh is charming! Er, appealing!

Apparently I went to bed just too early last night to see the Twitterscape and blogosphere explode with the news: Simon Singh is indeed going to be appealing against the ruling in the preliminary hearing, in his legal case in which he is charged with libel by the British Chiropractic Association.

Yay!

His book Trick or Treatment, co-authored with Edzard Ernst, is currently in the process of knocking my socks off (quite inconvenient and uncomfortable, actually, especially if I'm also wearing shoes at the time), and although I haven't got to the chapter on chiropractic yet, I've read the article that sparked all this controversy, and I'm becoming fairly familiar with the nature of his approach and the rigorous care with which he uses language when discussing these matters.

...

Read the full rant over at Cubik's Rube. Or just go sign this petition. This is actually about something important.

Views: 36

Tags: alternative medicine, bca, british chiropractic association, chiropractic, free speech, law, legal, libel, medicine, science, More…simon singh, skepticism

Comment by Matthew on June 5, 2009 at 11:18am
So this is a bit rambling and all over the place, but here goes:

I'm a chiropractor who practiced for 4 years. These sorts of articles bother the hell out of me because they are much like Intelligent Design arguments...based on cherry-picked sets of information and information that has nothing to do with anything.

His first point is about D.D. Palmer, the founder of chiropractic. It's safe to say that while D.D. is revered in that he brought chiropractic to the modern world, most chiropractors (all that I've spoken to) recognize that he was a bit nutty. He was wrong about a lot of things. To use his wrong ideas to argue against chiropractic is like using Darwin's ideas to argue against evolution. Of course he didn't have it all right...the information just wasn't there.

He then trots out this old line..."The British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence." This is patently false. There is evidence for chiropractic helping many of these ailments. While I will openly admit that chiropractic can't help these ailments EVERY time, it is frequently effective. I know as I've seen it in my office. There were times when I was treating a run-of-the-mill spinal pain problem and the patient would report relief of some other issue (asthma, ear infections, etc.) I'd like to add that M.D.'s are unable to help all of these ailments EVERY time as well and in some cases have no treatment at all. That doesn't mean you shouldn't go to the doctor or that they are dangerous. It just means they don't have the answer for YOU.

The fact that his professor friend Edzard Ernst apparently "learned chiropractic techniques himself and used them as a doctor" is ridiculous and quite different than being a chiropractor. I can go learn some engineering techniques and design a machine. I'm willing to bet that machine will not work as well as it could if an actual engineer designed it.

Now here come the fireworks. He states, "Nevertheless, conventional therapy is still preferable because of the serious dangers associated with chiropractic." This is such utter bullshit that I have a hard time containing my rage when I hear this. The side effects from chiropractic are very similar to the side effects of working out...muscle soreness, stiffness, pain. It is logical that these should be felt. After all, we're manipulating joints and retraining muscles. You are going to get a little sore. Can fractures occur...yes, but really only in very old feeble osteoporotic individuals. I don't adjust my 94 year old grandma the same way I do my triathlon patient, so it is safe for both. But to say that the side effect frequency is "very high" is misleading at best, and a bald face lie at worst. Most of my patients never experienced ANY side effects, and when they did they were quite safe. If you listen to ANY pharmaceutical ad, you know that every single drug on the market is more dangerous than some soreness. This doesn't mean they should be pulled off the market, it just means this argument against chiropractic is pathetic in comparison.

Indicating that an adjustment "involves pushing joints beyond their natural range of motion by applying a short, sharp force" is not inaccurate if not a scary way to put it. This is the same range of motion as cracking your knuckles. Have you ever worried about yourself or your friends / family because you know they crack their knuckles? "Oh I'm so worried about Mom...she cracks her knuckles and might fracture or dislocate them!!!" Give me a break. We're trained so thoroughly on how to adjust that this almost never happens unless there is some underlying condition that causes a person to be prone to these things.

THEN they trot out the coup de gras. The red herring to end all red herrings. The ultimate scare tactic and in my opinion the argument that lays this whole article to rest as a complete load of bull. The vertebral artery dissection caused stroke/death. This lie has been dispatched so thoroughly over the years that it should be embarrassing for anyone to bother using it anymore. Did you know that vertebral artery dissection is JUST AS COMMON in the non-chiropractic patient as in the chiropractic patient? It could happen backing out of your driveway, or in a chiropractors office. In other words...it's not the adjustment that causes it, the chiropractor is just unlucky enough to have it walk in the door. The patient mentioned in the article came to the office complaining of neck pain...most likely because her vertebral artery had ALREADY dissected before she got there. The pain is almost always indistinguishable from regular neck pain. This is the single most common study in chiropractic and it is absolutely, positively, not a concern. In fact, most of the vertebral artery dissections attributed to "chiropractic adjustments" were manipulations performed by non-chiropractors. We're talking, and I'm not exaggerating...kung-fu instructors, barbers, medical doctors. This argument is meant to inflame and terrify. It is irresponsible.

Chiropractic is much more effective than many people want to admit. There is mounting peer-reviewed evidence coming out regularly.
http://www.acatoday.org/level2_css.cfm?T1ID=21&T2ID=96
However, there is certainly more progress and research that needs to be done. We are a relatively new profession (founded in 1895...115 years old). At 115 years old, the medical community used bloodletting and blamed demons for most ailments. We've come a long way, we have further to go, but we're certainly not dangerous or ineffective.

Unfortunately, chiropractic has suffered a circular argument from the medical community until very recently. It goes like this....

"You chiropractors don't have any evidence, other than anecdotal. Therefore, your claims are false and dangerous."
"We see what you are saying and would like some money to do proper research."
"You can't have any money because you don't have any evidence."
"How can we get evidence if we can't get funding for research."
"Come ask for some money once you have some research."
etc.

You are over 400 times more likely to have a serious adverse side effect from a single aspirin. Have you ever thought twice or been concerned when taking an aspirin? I haven't. His conclusion that "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" is therefore false. Most drugs, of not all, are more dangerous than chiropractic.

One way to judge a medical profession for safety is the malpractice insurance rates. Insurance rates, as you probably know, are set by the number of claims and how much is paid out. Medical doctors pay a wide range in rates depending on their specialty and location but the best figure I found had them around $20K/year (it ranged from $10K-$200K). The average doctor of chiropractic pays around $2K. That's a big difference.

This article is misleading and dangerous. These same false claims have been made for years. In the late 80's the AMA was sued in court for spreading these lies and won.
http://en.wikipedia.org/wiki/Wilk_v._American_Medical_Association
That is really quite recent and rumors die hard. As I said, we still have a lot of progress to make, but we're getting there. But to say that chiropractic doesn't work is wrong. To say it's dangerous is libelous.

I don't understand why some are still attacking chiropractic. I think it stems from the misinformation the AMA spread for so many years. I have found that when M.D.'s and D.C.'s work together, the patient benefits the most. It is the patient that should be the focus, not who steps on whose toes, or philosophical differences. Articles like this serve only to spread misinformation. The intent is to remove patient choice, and that is wrong.

Did the BCA jump the gun on the lawsuit? Perhaps...I'm not familiar with British law. But I don't think they are just trying to squash all who disagree or don't like chiropractic. The trouble here is that so much of the information is false, misleading, and old hat. Does it do harm...yes. If I started telling people that medical doctors use chemicals they don't understand that often kill people, leave them as vegetables, and often don't work much better than placebo. Or that they needlessly cut people open and take things out for no good reason...you better believe I'd be sued. But this isn't anything the medical profession doesn't know...and they are constantly working to improve and do research. I think the motivation here is that chiropractic is a small player and still fighting for acceptance. Irresponsible articles like this one actually hurt the profession and utilization rates. I suspect their court case IS based on evidence, or at least I hope so. But it is difficult to publicly argue a scientific point...who, in the normal population, reads journals. The court case is a way to publicize those studies. Probably not the best way, but a way nonetheless.

Cubik's Rube...I find your argument more acceptable than Mr. Singh's. I tend to agree that he has a right to say these things. However, when there is information refuting your claims, I find it morally questionable to do so.
Comment by Matthew on June 5, 2009 at 11:27am
Edit: The AMA was sued and Lost. It won't let me edit or reply to my post. sorry.
Comment by Laura on June 5, 2009 at 2:25pm
I agree with Matthew on the issue of safety of chiropractic. As an attorney, I've defended chiropractors in malpractice cases and have done extensive research on vertebral artery dissection. The studies that claim a causal link between chiropractic and stroke are deeply, deeply flawed. They are mostly based on post-incident reporting by neurologists who assumed a connection between an adjustment and the dissection because the patient happened to have gone to a chiropractor (or received an "adjustment" from a friend, barber, or some similarly-untrained individual) in the days or even weeks before the stroke. Some of these people may have gone to multiple neurologists, causing their case to be reported more than once.

Studies that are more carefully done show no causation between chiropractic and stroke - like Matthew said, symptoms of vertebral artery dissection can include neck pain and sometimes cause people to go to their chiropractors. There are plenty of instances where chiropractors actually realized what was happening when the patient came in and sent them to the ER. Had they performed an adjustment that day, they would have been blamed for causing the stroke that was already happening. I spoke to a neurologist on this issue, who told me about a case in which a women suffered a vertebral artery dissection from turning her head when she was driving. Now, had she shown up at the chiropractor and gotten on the table without turning her head, she would have had the stroke during the adjustment. And, again, the chiropractor would be blamed simply due to poor timing.

So, yeah. I think more research needs to be done on the effectiveness of chiropractic - just like more research needs to be done on the effectiveness of a lot of treatments, both conventional and alternative, but in the meantime, we shouldn't avoid chiropractic because of misconceptions of its danger.

Let me also mention that people like to get money when they're injured. Sometimes they deserve it, and sometimes they don't. When you have a stroke, you usually can't sue anyone, because, hey, no one's to blame. But if you've been to a chiropractor in the days or weeks before your stroke, you have someone you can sue and try to get some money out of. These lawsuits then get on the news, and everyone assumes chiropractic is dangerous. But sometimes, it's just that people are using public misperception to their advantage to make a little cash.

In one of the cases I defended, the plaintiff had just gotten out of the hospital after suffering from viral meningitis. A couple weeks later, he starts having headaches, and he goes to the chiropractor he'd been seeing for years. He's adjusted. The next evening (while at a bar, pursuing his hard-drinking lifestyle), he starts to suffer from symptoms of a stroke. When he goes to the hospital, everyone assumes that the adjustment caused the stroke instead of the VIRAL MENINGITIS, despite the fact that the MRI images are not consistent with a dissection. In fact, they don't even take further diagnostic studies to investigate the cause of the stroke. That case was absolute B.S. This misconception of chiropractic as being dangerous takes on a life of its own, and causes people to see connections where there are none.

BTW - one of the articles we relied on in that case is the one referenced by Matthew above, about aspirin. It is entitled “A Risk Assessment of Cervical Manipulation vs. NSAIDS for the Treatment of Neck Pain,” by Vaughan Dabbs and William J. Lauretti. It concludes that aspirin “carries a hundred-times-greater chance of serious injury or death” than cervical manipulation.
Comment by Cubik's Rube on June 5, 2009 at 5:45pm
Okay, I'm not going to provide a comprehensive response to all the above (at least not on Friday night when there's pizza to be had and DVDs to be slouched in front of), but I have a couple of things:

First of all, on this subject, I'm glad I'm not one of the people in charge of making any important decisions, or whose opinions hold much sway on anything. There's a lot I don't know, and a lot of points on which I'm not sufficiently informed to be insistent.

One thing that seems to be clear, though, is that there's a great deal of variety in what comes under the heading of "chiropractic". I'm still in the middle of the relevant chapter in Singh's book at the moment, but the division between "mixers" and "straights" (which may be only unofficial and somewhat slang-y terms) seems an important one. A lot of working chiropractors who are also well versed in mainstream medicine may be doing a great deal of good out there in treating people for back and neck pain.

But the original formulation of chiropractic does seem, as Matthew says, "a bit nutty", to say the last. Its ideas about subluxations and "innate intelligence" don't seem to be remotely based in reality, or supported by any evidence that such things exist. It was initially claimed that almost all ailments originated in misalignments of the vertebrae, and for some time chiropractic completely denied the germ theory of disease. These are very shaky foundations on which to base a branch of medicine and claim that it can do so many wonderful things.

As for evidence of its effectiveness in treating all those problems... Well, it really doesn't seem to be there. I'd love to research this in more depth at some point, and cite actual case studies, and examine the specific data which supposedly counts in its favour, but that won't be tonight. For now, I'm going to carry on letting smarter and better-informed people than me decide what counts as good scientific evidence, but the consensus doesn't seem to be on your side. But however ill acquainted I am with the literature, I do know that "I know as I've seen it in my office" is a long way from being scientifically relevant. The plural of anecdote still isn't data.

As for the dangerous side effects, the same thing applies about doing some more research another day, otherwise any discussion won't become any more interesting than something you'd find in Monty Python's argument clinic. I don't know that much about the facts, which is why I'm not doing anything like campaigning for any particular chiropractic practices to be outlawed. Again, smarter people, etc. One example I will mention, though, from the exact page my bookmark happens to be at the moment, is of a Canadian study in 2001, which showed that "patients under forty-five years of age who had suffered torn arteries were five times more likely to have visited a chiropractor in the week prior to the damage being recognised than healthy individuals of a similar age". And they have enough other numbers to make me wonder whether the rage you have such a hard time containing isn't at least a little to do with wounded pride.

I've still left a lot un-addressed, but this has already gone on longer than I'd planned. What I would want to make clear, though, is that this post wasn't intended to be any kind of polemic against the entire field of chiropractic treatment. I am saving anything of that sort until I've looked into it more carefully. My main point here was about this court case, and how unhelpful I think it is to launch a financially crippling lawsuit over scientifically defensible criticism, in place of providing any supporting evidence.
Comment by Laura on June 7, 2009 at 1:48pm
Notice, though, that that study proves nothing about causation. Could it be that the symptoms of a torn artery include neck pain, which would cause more people suffering from this condition to visit a chiropractor than a "healthy individual"? I don't know who Simon Singh is, but I highly question his legitimacy if he's relying on the studies that I've looked at to claim that chiropractic is dangerous.
Comment by Matthew on June 8, 2009 at 3:12pm
First...my anger stems not from a bruised ego, but from frustration. Have you ever felt irritated when the religious bring up the same old tired arguments against evolution? Anyone with a brain and some unbiased information knows it's legit. That's how I feel about this nonsense. I've seen it so many times and it has all been refuted. But there are some anti-chiropractic crusaders that warp information, cherry pick "studies" and make the profession seem questionable if not quackery. Their information is no more reliable than The Discovery Institute. That being said, I'll address some of your points.

First...I'm surprised you typed so much with pizza and DVD's as the alternative. You are a stronger man than I.

The "straight/mixer" division is an antiquated concept. It's another reason I would question your source. There is a wide range of philosophies in chiropractic, just like there is in any profession. Some people are too extreme on the edges, but a vast majority fall somewhere in the reasonable middle.

We do see lots of organic results and there is tons of anecdotal evidence for this. I am perfectly aware that anecdotal evidence (like that from my own experience) is far from scientific. That's why we want to do the research to see if these results are legit, placebo, or only happen in certain individuals. There are plenty of now accepted health care concepts that began as anecdotal stories...medications that were intended for one use and expanded to other uses upon patient reports, for instance.

Basing any current opinions about a topic on its old foundations is shaky ground, indeed. You mention some things about chiropractic's founders that make you question the profession. Remember my point...medicine used blood-letting and blamed demons and spirits for hundreds if not thousands of years. I hope we agree that this is at least as shaky (if not more shaky) a foundation as chiropractic. But both professions have advanced and are continually trying to learn more. The Palmers were incredibly quirky and strange. But to attack current chiropractic based on them is not far from an ad hominem argument and not really worth our time.

The concept of innate intelligence is simply that the body has a tendency to heal itself if possible. Chiropractic holds that the body heals especially well when interference is removed. I don't think this is such a far-out concept at all. Why do we put neosporin and a band-aid on cuts? It prevents bacterial and viral infection and allows the body to heal itself more quickly and effectively because it isn't dealing with both the healing and the infection. Why do we adjust the spine? To remove nerve interference and increase communication between the body and the central nervous system to allow it to heal itself more effectively.

As far as research goes, I respectfully disagree that the research is not on my side. Are there articles that don't turn out in chiropractic's favor? Sure, but there are plenty that do support it as well. I unfortunately lost my bookmarks a few months ago and can't remember where I used to look things up and where some of the better articles are. I would suggest you start here: www.fcer.org FCER even has a weekly e-mail that sums up recent research on chiropractic (and they include both the good and the bad).

Also, to propose that standard medicine practices is based on research that is so much stronger is a bit questionable. If you look up many (if not most) medications in the Physician's Desk Reference, the mechanism of action is unknown or poorly understood. But we use the medications because they work as intended for the most part. There have been several medical practices that have been highly questioned, but still are standard.
Cholesterol lowering drugs show no evidence of a change in heart attack rates...so why do we use them? We're finding cholesterol isn't a cause, it's a symptom.
Arthroscopic knee surgery for arthritis has been found to have no effect, but is still being done (as far as I know) (http://www.jfponline.com/Pages.asp?AID=7419&issue=March_2009&UID=).
Flu morbidity/mortality rates have not changed since the introduction of the flu shot...yet they are heavily promoted and tons of dollars are spent on them each year (I suspect they'll figure out how to make it effective eventually, but we don't have it nailed down yet. We don't need to throw flu vaccines out the window as quackery, more research is needed.)
Spinal fusion for back pain has been shown to be less than 50% effective, and the rates drop after 5 years post-surgery. In fact, it usually causes additional issues down the road. It is not practiced in much of Europe for this reason...they refer people to chiropractors. But I can't tell you how many people came into my office because spinal fusion was recommended and they thought that chiropractic was their last ditch effort to avoid surgery.

I prevented lots of surgeries with good old conservative chiropractic care. I know this isn't hard scientific data, but ask any chiropractor and they'll tell you the same thing. I have spoken to neurosurgeons and orthopedic surgeons who read all the same junk Mr. Singh is spouting (or heard it from professors) and believed it. Only after watching patient after patient come back to them pain free and no longer surgical candidates do they change their minds. And sometimes they STILL don't due to their biases.

I have a step-sister who is a grad student and works for a company that "cleans and edits" pharmaceutical company research articles. She has been horrified to see their practices. The study will come in and her job is to figure out who to include and who to exclude in the next round study to make the drug look as effective as possible. In other words, they don't just publish the initial study...they do a study, pick the ones who had the fewest side-effects, and the most response...then they do another round of studies with the cherry picked candidates. This is not scientific, and it is not reliable or best practices.
She recently had a case where a company was comparing their new drug to the current front-runner on the market. In order to have their results look statistically significant, they found they had to have the patients in the study STOP their current medication (resulting in a spike of symptoms and a resurgence of the disease) before starting the new drug. Thereby making the new drug look like it had amazing effects when in fact it was the same or slightly less effective than the current brand. So I wouldn't rely too heavily on traditional methods for "scientific" studies. If they understood what they were doing completely, there wouldn't be any side effects (which should really be called unexpected/undesired effects).

As far as safety, I just can't explain clearly enough how weak his standing is. You can go to Dr. Dino and hear some pretty convincing language and sciencey sounding stuff that makes evolution seem downright silly. But we all know it's bunk. That is exactly as questionable as the arguments Singh is using. You mention a study, and Laura addressed it above. As a comparison, I'm willing to bet that people who experienced chest pain were much more likely to go to the hospital within a week, where it will likely be found that they had a heart attack. That doesn't mean the hospital caused the chest pain or the heart attack. Vertebral artery dissection causes neck pain...for which people go to the chiropractor, same deal. I highly recommend the book, ""Current Concepts: Spinal Manipulation and Cervical Arterial Incidents" which is incredibly comprehensive and the source for what I would tell you about safety anyhow.

I would also encourage you to research the safety of standard medicine. I assure you, it's more dangerous than you think. The US Health and Human Resources reports around 98,000 deaths/year due to medical errors, which doesn't include unexpected adverse events to medications that were properly administered. Then the number is much higher. (http://www.ahrq.gov/qual/errorsix.htm) This places it around #6 in the causes of death in the US according to the CDC. In comparison, there are no reported deaths due to chiropractic adjustments that have been verified. None. So to question chiropractic and its safety is quite ridiculous when you put it in perspective. And to suggest that traditional treatment (usually drugs) is safer is laughable.

I know YOU are not attacking chiropractic, but Mr. Singh was. What he said is not scientifically defensible, because these points have been asked and answered. I'm hoping that a good part of the BCA's court case is doing exactly what you want...providing supporting evidence to prove their point. But he didn't publish this article in a scientific journal where response papers can be published. He wrote a book for the public, so the case needs to be taken care of in the public forum. The information to counter his points is out there, he just chose to ignore it. Again, I think he has a right to say the things he does, just like I think any idiot can go peaceably demonstrate in the street. I just don't think that any of his opinions hold any water or are worth reading or considering. I'm trying to start giving the evidence you requested, but I know there's loads more out there.

Here's a letter from the ACA to the Wall Street Journal regarding this book: http://www.acatoday.org/record_css.cfm?CID=3035

I'm hoping you'll do the research you want before considering Mr. Singh's book as worthwhile. And I hope you do it soon. I'm confident you'll be surprised at how wrong he is. Please keep in mind there is a long-standing hatred of chiropractic from the medical community and try to filter through that. Please also keep in mind that there is a backlash of overly loud chiropractors in response to that, and try to filter through them as well. There are good chiropractors and bad chiropractors, just like there are good doctors and bad doctors, good scientists and bad scientists.
But as a profession, I believe we are an incredibly safe, effective alternative to drugs and surgery. Which is not to say that drugs and surgery are evil and always unnecessary. Like I always say...when drivel like this stops distracting us, the two approaches to health care can finally start working together for the benefit of the patient. For the most part that's happening, but not as quickly as I'd like.

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