Sunday, 28 April 2013

Chiropractors

You may have heard in the news recently that the Libel Reform Bill finally made it through both Houses of Parliament and is now just awaiting the formality of Royal Assent. This is great news for Britain as a country; in recent years we have increasingly become an international joke for the state of our libel laws, some of the laughable decisions that judges came up with (most notably, Justice Eady), the eye watering costs involved in defending libel actions and for becoming the centre of so called Libel Tourism - the phenomenon where foreign billionaire oligarchs use our outdated and inappropriate libel laws to sue people in other countries that never even published their criticisms in this country.

But what has all this got to do with chiropractic? Well, one of the most famous libel cases of recent years was The British Chiropractic Association vs Simon Singh. Singh, a mathematician by trade that has also become a science journalist and author of several popular science books, published this article in 2008 criticising the BCA for making claims of being able to cure multiple childhood afflictions including colic, excessive crying, bed wetting, asthma, ear infections, feeding problems and much more all through manipulating their spines. Hopefully, most of you are now thinking "How on Earth would that work?". Well, it doesn't. Singh correctly called such treatments 'bogus' and was promptly sued by the BCA. Due to the way libel laws worked in this country at the time it took 4 years of court actions, appeals and costs in the hundreds of thousands of pounds for Singh to defend himself. He initially lost his case but, fortunately, the appeal courts eventually found in Singh's favour and ordered the BCA to pay his costs; costs that all but financially ruined the innocent Singh. The bravery required to fight such a cause with such potentially high personal costs should not be underestimated. In light of defeat it might have been reasonable for the BCA to apologise, to take a look at itself, what it does and look to reform itself. This is not what happened. Richard Brown, the President of the BCA and proud holder of a prestigious Doctor of Chiropractic degree from the Anglo-European Chiropractic College, instead issued a bullish response where he recites many of the tropes that caused the problem in the first place; a classic tactic frequently deployed by pseudoscientists the world over.

BCA vs Singh was one of many reasons why a growing well spring of public concern about our libel laws led to the formation of the Libel Reform Campaign whose triumph last week, despite the efforts of some of our worst Parliamentarians like Lord Puttnam and Sir Edward Garnier, we should all be proud of. I wrote the bulk of what is to follow in this post several months ago, it isn't difficult to find ways to criticise chiropractic, but I wasn't entirely comfortable with the idea of publishing it in case an organisation like the BCA decided to take offence at it. This blog is only read by a few thousand people per month but if an advocate of chiropractic were to stumble across it they certainly wouldn't be happy, and the thought of having to go through even a fraction of what Simon Singh endured is, frankly, scary. I suspect I won't be the only blogger this month that finally feels they can publish what, in any other western society, would be considered common sense and in the public interest. So, introduction over; let's get to it....


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The cornerstone of chiropractic (which I'll mostly be abbreviating to 'chiro' as it's a pain in the neck, geddit!, to type it out all the time) is a technique called subluxation. Subluxation is a real thing, it refers to when one bone displaces over another, these can cause quite serious complications, as you might expect, and can be detected by a trained osteopath or by x-ray or other exam. Chiropractors (chiros) use the term subluxation much more loosely though, in fact it has no real definition in their circles. Blinded studies have repeatedly shown that a) different chiros cannot agree where a subluxation has occurred in a patient and b) that different chiros do not agree on whether the same subluxation correlates with the same illness or set of symptoms. This should immediately set off a red flag as it clearly indicates that there is no actual modality to the alleged basis of what chiropractors do.

The work of fiction that is chiropractic was first made up in 1895 by a man with an idea but no medical training whatsoever. His name was Daniel David Palmer and his idea was that greater than 95% (yes, 95%) of all health conditions are caused by subluxations that, although they were mostly undetectable at the time, somehow manage to stop a life force that apparently flows through us all. All you have to do to be cured is to allow someone with no qualifications to speak of to dangerously manipulate your possibly already painful spine so that your life force can flow freely once more and heal you. I'm not making this up; the premise of chiro is that life force falls out of the sky, enters us through our skulls and is then distributed through our body along our spine.

Palmer, shockingly, wasn't taken seriously in the medical profession and was on the verge of being banned from practising chiropractic all together, as it clearly has the potential to do harm whilst having no basis for achieving anything good; what's known in the medical community as being dangerous and unethical. Like all quacks everywhere, and unlike all scientists everywhere, Palmer decided that instead of changing his opinion in the light of the evidence he would merely state his case ever more vociferously and claim to be a victim of persecution; a proud tradition maintained by chiropractors the world over to this very day. His cunning plan was to claim that chiropractic was a religion which would basically allow him to say anything he likes with impunity. This happens to be the same tactic used by charlatan extraordinanaire and mediocre sci-fi writer L. Ron Hubbard with dianetics in the late 1940s. His despicable and demonstrably wrong views on mental health were about to get him in a lot of legal hot water and so he claimed that it was actually a religion - and so Scientology, one of the worlds fastest growing and most dangerous cults, was born. For better or for worse, Palmer wasn't forced to play this gambit; public opinion softened and he was allowed to get away with practising nonsense on the gullible and ill informed.

Many modern chiros have tried to distance themselves from these shady beginnings and desperately try to bring a veneer of legitimacy to what they do by not mentioning any of the life force woo woo stuff. They may well be able to call upon a list of published papers that support their views but these are universally poorly designed, ill-executed, badly controlled studies riddled with conflicts of interest that supposedly legitimise their points and therefore their fees; but these papers do not stand up to much scrutiny. Not all scientific, peer reviewed articles are created equal; unfortunately there is such a thing as bad science and it can take a lot of digging around to separate the wheat from the chaff.

Luckily, there is an organisation called the Cochrane Collaboration and what they spend their time doing is going through all the research that has ever been done on a particular medical intervention and amass the data into one coherent, authoritative review; this normally takes place some years after a treatment has been introduced so that time can be allowed for high quality, large studies to be done. It is difficult, laborious and vital work and a Cochrane Review is internationally considered to be the highest possible standard in evidence-based healthcare. They are named after Archie Cochrane, a British epidemiologist who believed that the best way to see if a treatment actually worked was through randomised, blinded trials. If they say something is beneficial then it probably is. If they say it doesn't work or is dangerous then it is quite likely the final nail in the coffin of said treatment. They might also say that there is no clear evidence either way and that the treatment is indistinguishable from a placebo. This is the category that chiropractic fell into in a review in 2011. The reviews are regularly updated so that new evidence can be factored in.  They can say this with confidence because they are independent and exhaustingly thorough. Part of producing such a comprehensive, systematic review is sorting the good papers from the poor ones when it comes to deciding which studies should be considered. A study where the inventor of a new treatment tests it out just once on his wife and she says she's much better now thank you darling is clearly not going to cut the mustard; that's not how you build a reputation for quality.

The reason I am mentioning all this is that I want to ask you a question: once the Cochrane review for chiropractic was released do you think that, like good responsible practitioners of evidence based medicine, the chiropractors held up their hands and said yep, it doesn't look like this works, we should either conduct some more rigorous studies or maybe even quit this charade altogether; or do you think they merely began libelling the Cochrane Collaboration, that bastion of modern medicine, crying Foul Play! and Conspiracy! and generally doing anything they could to weasel themselves out of their grubby, little hole other than providing good evidence for their claims? It's hard to believe, I know, but what they did was claim that they were screwed over because certain trials weren't included, trials that by their own admission were '1) non-randomised, observational or uncontrolled; 2) or trials where the chiropractor delivered the treatment in both study arms'. What that means is that the trials weren't double blinded. What that means is that the trial wasn't worth the paper it was written on. They then went on to say that the 'slavish adherence' to the blinding of patients and treatment providers shouldn't be considered a mark of quality in a study. If this were a story in a book or film you wouldn't believe it because it's just too stupid. The thing about the studies that the chiros like is that they're very poor and would be unlikely to ever get through the peer review process of most journals, indeed, they don't tend to make it through very often at all. They're not the kind of people to let a little thing like being considered a complete joke stop them though, so what they did is they made up their own journals like the Chiropractic Journal and the Journal of Chiropractic Medicine where they're not quite so fussy about things like the rules of evidence, logic or not being a dick.

So, given that all the evidence is against them, how is it that chiropractic continues to do well in 21st century Britain? There seem to be many reasons, a lack of public awareness as to what chiro actually is; the wilful deceit of organisations like the BCA (thank you Libel Reform Bill for letting me say that); endorsement from high profile idiots like Prince Charles; and an inclination for people to fall for the Natural Fallacy, the idea that because something is natural it is automatically good and/or better than an 'unnatural' alternative. Arsenic is natural, I recommend you don't eat it.

Another difficulty is where the burden of proof falls. In every day life, and certainly in the realm of science, if someone makes a bold claim then they have to provide evidence for that claim, especially when that claim goes against the established or perceived facts, and the more extraordinary the claim the more extraordinary the evidence required to back it up. The modality of chiro is a bold claim indeed but somehow we find ourselves in a situation where they don't need to do anything to prove that what they say is correct; instead, the scientific and sceptical communities are left trying to prove a negative. Frustratingly, you can never 100% prove a negative. Although it can't be done conclusively it is possible to use science to put bounds on the likelihood of a phenomenon existing. If all possible tests have been carried out at a high degree of sensitivity and nothing is discovered then it can be considered highly likely that the phenomenon isn't real. If the response after such testing from the proponents of the theory is merely 'well it doesn't work like that' or some such other bull crap then we have strayed into the realm of special pleading, one of the top five logical fallacies you're likely to encounter.

Another problem is anecdotal 'evidence'. Anecdotal evidence, of course, isn't evidence at all, it's an anecdote. "Well, it worked for me," is a defence I have often encountered from people. I'm sure that they believe it did, but that still doesn't mean that it works. For example, many people will only seek treatment once their symptoms have become quite bad and they get desperate for some sort of relief; however, in most chronic illnesses there is something known as regression to the mean. Yes, the symptoms may get bad periodically but then, after a while, they settle down into their more usual form - they regress to the mean. So if, a few days after a treatment, the symptoms settle back down it can be very easy to attribute the benefit to whatever the most recent treatment was. This is the post hoc ergo propter hoc logical fallacy which basically translates as 'after this, therefore because of this'; put another way, it is confusing correlation with causation. Also tied up in this is confirmation bias; this is where we tend to believe what we want to believe and ignore evidence to the contrary. For example: a psychic says they can predict the sequence of a shuffled deck of standard playing cards. Maybe they go through the deck several times trying to display their talents. Over the course of several hundred guesses the chances are that they'll get the right card every now and then (I don't know the exact odds); I would interpret this as them not having any special powers to speak of, of course they got the right answer a couple of times, it would be weird if they didn't; but they interpret the same data as confirming that they have powers, the times when it worked weren't random but examples of when their powers 'switched on'. Their inherent bias confirmed their initial premise. This is a very easy trap for us all to fall into.

Another factor is self defence. Someone who opts for an alternative treatment (point of order: there is no such thing as alternative medicine, there is science-based medicine and there is quackery) might be a bit embarrassed about doing so. They're going out on a limb, they know there's probably nothing to it, maybe they've been teased by a horrible, mean sceptic like me, and so they may fall into a trap of defending the alternative treatment as a way of legitimising their choice.

These psychological reasons then: confirmation bias, confusing correlation and causation, optimism bias, risk justification, suggestibility, the Natural Fallacy, the Lottery Fallacy, embarrassment and many others all play their part. It is all but the definition of the scientific method to find ways of excluding these inherent biases that we all have. I know, though, for all this, that there are people out there who just don't trust science; they don't like it, they don't understand it, they think it is a matter of opinion. These people are wrong but if I haven't convinced them of that by now then I'm unlikely to ever do so. In one final attempt to show them the light, if you'll forgive such an overtly religious phrase, let's look at another viewpoint, let's not take my word for all this; question everything. Perhaps the people we should listen to most carefully are those lovely chaps down at the General Chiropractic Council. Although they are obviously very keen on promoting their particular brand of nonsense they, nonetheless, have no choice but to admit that the idea that subluxations are the cause for illness 'is not supported by any clinical research evidence' and that this idea should be taught as 'a historical concept and not a current theoretical model'. So there you have it, friends; don't take my word for it. If your back hurts go to your GP and ask to be referred to an osteopath. Job done.

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