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OBSERVATIONS: Edzard Ernst Chiropractic for paediatric conditions: substantial evidence? BMJ 2009; 339: b2766 [Full text]

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Quackery, chiropractic and alternative medicine

Peter C Gøtzsche   (14 July 2009)

Substantial evidence?

Jennifer E. Bolton   (15 July 2009)

Interpreting insufficient evidence: open to judgement

Adrian R White   (16 July 2009)

No evidence favoring chiropractic

Joe Magrath   (17 July 2009)

Re: Substantial evidence?

Edzard Ernst   (17 July 2009)

Safety

George T Lewith   (17 July 2009)

Are you being serious?

John S Garrow   (17 July 2009)

A Hoax?

E Ernst   (20 July 2009)

Criticism of Chiropractors: No Competing Interests?

RICHARD A BROWN   (22 July 2009)

Asymmetry in standards of evidence for efficacy and safety

Michael Power   (23 July 2009)

Brown's comment

E Ernst   (23 July 2009)

What is Quackery

James M May   (23 July 2009)

Re: Criticism of Chiropractors: No Competing Interests?

Simon J Baker   (23 July 2009)

Response to Brown

Richard Bartley   (23 July 2009)

Reply to Brown 22 July 2009

Joe Magrath   (25 July 2009)

Do chiropractors treat illnesses or not?

Peter J Flegg   (25 July 2009)

Quackery, chiropractic and alternative medicine 14 July 2009
Peter C Gøtzsche, Director Nordic Cochrane Centre, Rigshospitalet, DK-2100 Copenhagen Send response to journal: Re: Quackery, chiropractic and alternative medicine	There are strong political pressures to reimburse patients who seek alternative practitioners, to make alternative medicine part of the medical curriculum, and to have our medicine agencies approve of alternative remedies. I advice anyone who is interested in this to read the paper in the 11 July issue by Richard Brown, vice-president of the British Chiropractic Association (1), and the sobering response by Edzard Ernst, Professor of Complementary Medicine, in the same issue (2). Ernst writes that the website of the British Chiropractic Association makes statements about childhood asthma, sleeping problems, otitis, colic, feeding problems, sleeping problems, and prolonged crying (2), but also shows why the references offered by Brown - and which Brown calls "substantial evidence" - are unconvincing. From this year, the main textbook of medicine for Danish medical students contains a chapter on alternative medicine (3). I was asked by the editors to write this chapter, probably because they wanted it to be evidence-based, and looked for systematic reviews on the most popular treatments: manipulation of the spine, massage, reflexology, acupuncture, healing, craniosacral therapy and homoeopathy. The results were depressing, even for the effect of acupuncture on pain, which we have analysed in a systematic review (4), and for the effect of manipulation on back pain (5). The authors of the back pain review used very complicated statistics, with indirect comparisons. There was some effect on pain and a small effect on functional ability, but it is a problem that the trials cannot be blinded and that such results could therefore be due to response bias. Furthermore, functional ability was assessed as a score, and a small improvement in such a score does not necessarily mean that the patient has been helped. Another Cochrane review did not find an effect of manipulation of the cervical columna (6). Side effects were reported in 31% of the trials. They were benign, transient, and included headache, radicular pain, thoracic pain, increased neck pain, distal paraesthesia, dizziness, and ear symptoms. The rate of serious adverse events could not be determined in the review. However, permanent tetraplegia has occurred after manipulation, and in one such case, a Danish court decided that there is an increased obligation to inform healthy people about harms before the treatment, even though they are very rare, and as this had not been done, the patient won a compensation for the damages (7). The Danish law on quackery no longer exists, and it is also difficult to define exactly what constitutes quackery. But tort law does. In my opinion, it should be made illegal to apply forceful manipulation of the cervical spine, whereby the practitioner grabs the head by the two hands and suddenly swings it to one side. I once practiced rheumatology and saw this done by a colleague. I was terrified and decided that under no circumstances would anyone be allowed to do this to me. It is scandalous that the British Chiropractic Association has filed a law suit against Dr Simon Singh and that the judge has accepted it. Singh wrote what he thinks about the effects of chiropractic and, no doubt, millions agree with him. The British libel laws need a major rehaul, as they have been used repeatedly to harm honest people, newspapers and scientific journals that merely convey their interpretation of the scientific evidence and expose the hypocricy. As the BMJ editor says: "Keep libel laws out of science" (8). Similarly, I will argue: "Keep alternative medicine out of drug regulation, unless randomised trials have shown an effect". It is a tragedy that the UK Medicines Agency has approved a homoeopathic remedy (9), with indications. Anyone will a small chemistry exam will know that homoeopathy just cannot have any effect on anything, apart from filling the homeopaths' purses. 1. Brown R. Chiropractors: clarifying the issues. BMJ 2009;339:b2782. 2. Ernst E. Chiropractic for paediatric conditions: substantial evidence? BMJ 2009;339:b2766. 3. Gøtzsche PC. Alternativ behandling. In: Ove B. Schaffalitzky de Muckadell, Stig Haunsø og Hendrik Vilstrup, red. Medicinsk Kompendium, 17. udg. København: Nyt Nordisk Forlag, 2009, kap. 75. ISBN 978-87-17-03933-9. 4. Madsen MV, Gøtzsche PC, Hrobjartsson A. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ 2008;338:330-3. 5. Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low-back pain. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD000447. 6. Gross A, Hoving JL, Haines T, Goldsmith CH, Kay TM, Aker P, Brønfort G, Cervical Overview Group. Manipulation and mobilisation for mechanical neck disorders. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004249 7. Kiropraktoransvar for total lammelse. Ugeskrift for Retsvæsen 1991; sag 13–343/1987 (Østre Landsret 31.10.1990). 8. Godlee F. Editor's choice: Keep libel laws out of science. BMJ 2009;339:b2783. 9. Delamothe T. Thinking about Charles II. BMJ 2009;339:b2771. Competing interests: None declared
Substantial evidence? 15 July 2009
Jennifer E. Bolton, Director of Research Anglo-European College of Chiropractic, BH5 2DF Send response to journal: Re: Substantial evidence?	How much more time and effort must be expended on the debate currently raging as to ‘Is there/isn’t there sufficient research evidence to substantiate the treatments of chiropractors?’ The answer, on balance, is that the research evidence for chiropractic treatment of certain conditions is weak, and yes, of course, we need much, much more. In the meantime however, we have to rely on evidence from other sources, which means the clinician’s expertise and experience and also the views and wishes of the patient. In the absence of research evidence, provided the treatment is safe and of reasonable cost, then these other forms of evidence are a legitimate part of the evidence-based model. It is nonsensical, and not in keeping with evidence-based practice, to be concerned only with research evidence when discussing the ‘evidence’ for particular treatment approaches. To do so is a dogmatic and self-serving perspective that has no place in an inclusive and modern day understanding of evidence-based clinical care. Competing interests: None declared
Interpreting insufficient evidence: open to judgement 16 July 2009
Adrian R White, Clinical Research Fellow Peninsula Medical School, ITTC Building, Plymouth PL6 8BX Send response to journal: Re: Interpreting insufficient evidence: open to judgement	Although it is chiropractic that is attracting debate now, the same arguments could have been made about acupuncture, 15 years ago. There are similarities between the two therapies. In particular, they both were previously considered implausible because they were originally based on unscientific principles: acupuncture is now gaining some scientific credibility from an increasing amount of neurophysiological evidence.1 Simon Singh makes the same point for chiropractic on his website. This does put these therapies in a different category from ear candles and crystals. Also, acupuncture and chiropractic are both physical therapies with well recognised difficulty in devising inactive placebo controls, with all that brings for the interpretation of trials.2 Maybe this similarity could extend to evidence of effectiveness as it evolves over time? While 15 years ago acupuncture was supported largely by clinical opinion, the situation has now changed radically: current systematic reviews conclude that acupuncture is superior to sham for treating postoperative nausea and vomiting,3 chronic low back pain,4 tension-type headache,5 and postoperative pain.6 And moreover, physical treatments clearly bring some other therapeutic effects which, all too easily dismissed as ‘expectation’, are in fact often worth it to the patient: a large study on acupuncture for low back pain found it to be considerably more effective than evidence based conventional care.7 Research on spinal manipulation lags behind that of acupuncture. Most people would probably not argue that the current evidence on chiropractic for paediatric conditions amounts to anything near ‘substantial’.8 But it is still open to judgement whether the evidence amounts to substantial evidence of lack of effectiveness when the findings include (selecting simply for the sake of establishing hypotheses) ‘observed positive effects on quality of life’, ‘less crying … noted by the parents’, ‘data provided .. are insufficient’, ‘positive conclusion regarding asthma’, "weak evidence" , and "both treatments appear to offer significant benefit to infants with colic".9 Acupuncture and chiropractic are both easy targets. It seems, from our experience with acupuncture, that the jury (the scientific one, at least) may actually still be out on paediatric chiropractic. As so often, ‘more research is justified’. Adrian White Competing interest. Adrian White is employed as part-time Editor of Acupuncture in Medicine, the journal of the British Medical Acupuncture Society. 1. White A, Med EBoA. Western medical acupuncture: a definition. Acupunct Med 2009;27(1):33-5. 2. Cummings M. Modellvorhaben Akupunktur - a summary of the ART, ARC and GERAC trials. Acupunct Med 2009;27(1):26-30. 3. Lee A, Fan LT. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev 2009(2):CD003281. 4. Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, et al. Acupuncture and dry-needling for low back pain. Cochrane Database SystRev 2005(1):CD001351. 5. Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for tension-type headache. Cochrane Database SystRev 2009(1):CD007587. 6. Sun Y, Gan TJ, Dubose JW, Habib AS. Acupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials. BrJ Anaesth 2008;101(2):151-160. 7. Haake M, Muller HH, Schade-Brittinger C, Basler HD, Schafer H, Maier C, et al. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med 2007;167(17):1892-1898. 8. Godlee, F. Keep libel laws out of science. BMJ 2009;339:b2783. 9. Ernst, E. Chiropractic for paediatric conditions: substantial evidence? BMJ 2009 339: b2766. Competing interests: Adrian White is employed as part-time Editor of Acupuncture in Medicine, the journal of the British Medical Acupuncture Society
No evidence favoring chiropractic 17 July 2009
Joe Magrath, Retired chemist N/A Send response to journal: Re: No evidence favoring chiropractic	Jennifer Bolton's comment makes no sense. With the possible exception of low back pain, there is no compelling evidence that chiropractic is safe and effective for anything. Indeed, an understanding of anatomy and physiology tells us that chiropractors cannot alter the relationships among bones in the spine. We also know that transplanted organs work well without any connection to the spine; yet chiropractors continue to make claims for treating visceral ailments (asthma, colic, etc.). One would think the BCA provided the best evidence in favor of treating such problems; yet their evidence does not support their therapies. In the absence of evidence, Ms. Bolton would have us rely on "clinician’s expertise and experience and also the views and wishes of the patient." In the past, that led to such treatments as bleeding, leeches, trepaning and violent purgatives. It was not until we learned that we can be fooled by "expertise and experience," and adopted scientific methods, that we began to make progress in health care. After 114 years, chiropractic has not brought us anything better than (grocer) DD Palmer's imagination to support most of their claims. I interpret Bolton's last two sentences as meaning chiropractors should carry on "as if" they offer legitimate treatments (while they try to develop the evidence for them). That argument is irrational. Competing interests: None declared
Re: Substantial evidence? 17 July 2009
Edzard Ernst, Director Complementary Medicine Peninsula Medical School University of Exeter 25 Victoria Park Road Exeter EX2 4NT UK Send response to journal: Re: Re: Substantial evidence?	What is JE Bolton trying to convince us of? “The research evidence for chiropractic treatment of certain conditions is weak …” ??? No, for some of the disputed conditions it is negative (e.g. asthma) and for others it is non existent (1). This obviously means we should not recommend chiropractic for any of these conditions. The BCA should state this clearly rather than sueing for libel a science writer who dared to point out these discrepancies. We are expending time and effort because the BCA still insist that there is “substantial evidence” (2) where, in fact, there is virtually none. References 1. Ernst E. Chiropractic for paediatric conditions: substantial evidence? BMJ 2009;339:b2766 2. Brown R. Chiropractors: clarifying the issues. BMJ 2009;339:b2782 Competing interests: None declared
Safety 17 July 2009
George T Lewith, Professor of Health Research University of Southampton, Primary Medical Care, Southampton, SO16 5ST Send response to journal: Re: Safety	I note Edzard Ernst’s defence of the chiropractic libel case does not substantively mention the issue of safety. I have had considerable correspondence with Professor Ernst in New Scientist which suggests that there is an excellent case controlled study indicating that the risk of stroke is not increased by chiropractic (Cassidy et al. Spine. 2008; 33: S176-S183; Lewith. New Scientist 2009 -Chiropractic case - opinion). Professor Ernst assures me that he is preparing a detailed response with respect to the issue of safety but this has not yet been made public. I look forward to the publication of this response as it is particularly Germaine to the issue under discussion. Competing interests: None declared
Are you being serious? 17 July 2009
John S Garrow, retired physician London WD3 7DQ Send response to journal: Re: Are you being serious?	I read the response headed "substantial evidence?" several times while trying to decide if it is a joke. Bolton asks how much more time and effort is needed to substantiate the treatments of chiropractors, since at present the evidence of efficacy is weak. Her reply is that "of course" much, much more research is needed. She declares that she has no competing interests, but her job is director of an institution researching chiropractic. I think this interest has biased her judgement. An unbiased person might conclude that the situation does not need more research into chiropractic teatments for childhood conditions, since we already know from many trials that chiropractic is not effective for these conditions. Even the most generous critic might say that if Bolton wants to do more of this research she is the person who should do it, and try to show that it is effective. But she insists that in the absence of good RCT evidence we must be guided by "the clinician's expertise and experience and also the views and wishes of the patient." The reason that I still suspect that the response is a hoax is the way in which she condemns the attitude of those who want evidence of efficacy before they will endorse the treatment. Her final sentence is this: To do so is a dogmatic and self-serving perspective that has no place in an inclusive and modern day understanding evidence-based clinical care. Doesn't that brilliantly describe the situation in which she has landed herself? Competing interests: Preference for treatments that have been shown to be effective by good RCTs.
A Hoax? 20 July 2009
E Ernst, Director Complementary Medicine Peninsula Medical School, University of Exeter, 25 Victoria Park Road, Exeter, EX2 4NT Send response to journal: Re: A Hoax?	Prof Garrow suspects Bolton’s comments to be a hoax, and I spotted several other funny remarks amongst the comments. White seems to think that the evolution of the evidence-base of chiropractic might follow that of acupuncture. Why? Just because two treatments are not plausible, they will not necessarily develop along similar paths! White also points out that “it is still open to judgement whether the evidence amounts to substantial evidence of lack of effectiveness” of chiropractic. Is this a hoax too? On a theoretical level, it is not normally possible to employ science for proving a negative. On a practical level, responsible clinicians are guided by positive proof and do not wait until “substantial evidence of lack of effectiveness” tells them not to use this or that therapy. In other words, until we have good evidence that a treatment works, we should be very cautious recommending it. Finally we have Lewith raising the subject of safety of chiropractic. His remarks are funny because safety is neither at the heart of the libel case, nor is it a central theme of the BCA’s evidence[1], nor of my analysis of that evidence.[2] But safety is certainly a subject that must be uncomfortable to the chiropractic profession. Chiropractors cannot dispute that about half of all their patients suffer transient adverse effects after spinal manipulation. This is demonstrated by a mountain of their own data.[3] These adverse effects are usually mild to moderate, but often serious enough to notably reduce the patient’s quality of life for one or two days. If this were the full story, a risk-benefit analysis of chiropractic for the disputed conditions would already turn out to be negative. But there is more! Well over one hundred very serious complications, mostly vascular accidents after neck manipulation, are on record.[4]Chiropractors dispute that the association is causal by nature.[5] Yet the totality of the evidence seems to indicate otherwise.[6] The most generous interpretation of this evidence cannot lead to any decree of certainty that spinal manipulation is not the cause of vascular accidents, strokes and deaths. Applying the precautionary principle, one should therefore not recommend chiropractic but warn patients not to use this form of therapy. References (1) Brown R. Chiropractors: clarifying the issues. BMJ 2009; 339(b2782). (2) Ernst E. Chiropractic for paediatric conditions: substantial evidence? BMJ 2009; 339:b2766. (3) Ernst E. Prospective investigations into the safety of spinal manipulation. J Pain Sympt Managem 2001; 21:238-242. (4) Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79:50-65. (5) Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL et al. Risk of verebrobasilar stroke and chiropractic care. Spine 2008; 33(45):S176-S183. (6) Gouveia LO, Castanho P, Ferreira JJ. Safety of chiropractic interventions: A systematic review. Spine 2009; 34:E405-E413. Competing interests: None declared
Criticism of Chiropractors: No Competing Interests? 22 July 2009
RICHARD A BROWN, Chiropractor Gloucestershire, United Kingdom GL5 1AU Send response to journal: Re: Criticism of Chiropractors: No Competing Interests?	In his commentary (1), Edzard Ernst has deconstructed a single sentence of my paper (2) and has selectively overlooked the main thrust of the article. While the article focused on matters related to a range of issues, not least of which were the defamatory statements made of the British Chiropractic Association (BCA) by Simon Singh, Ernst devoted the entirety of his response to a dissection of evidence put forward by the BCA in response to Singh’s assertion that there was ‘not a jot’ of evidence existing in relation to chiropractors being able to help (not treat, or cure) various childhood conditions. Regarding competing interests, he omits to mention that he, with Simon Singh, co-authored a book on alternative medicine (3). Fiona Godlee, in her editorial (4), describes Ernst’s analysis as ‘a demolition’ and supports calls to keep the libel laws out of science. The BCA does not contest the need for further research. It is quite proper that responsible health professionals should seek to improve their knowledge by undertaking rigorous trials to test hypotheses and clinical experience. Contrary to Ernst’s assertion that the evidence denying benefit is strong, the reality is that there is a paucity of comprehensive clinical trials in this area and further quality research is needed. There is clearly, however, more evidence than ‘not a jot’ and it was quite wrong of Singh to label the treatments promoted by the BCA as ‘bogus’. The case has clearly ignited fierce debate, and a number of correspondents have allowed emotion and bias to cloud the pursuit of scholarly debate, dismissing chiropractic as quackery (5) and caricaturing the profession as deserving of unprofessional language (6). Surely such vitriol is not the way to advance debate in the pages of a prestigious medical journal? Amongst the responses, a physiotherapist has sought to elevate the status of his profession at the expense of chiropractic by alleging that ‘[chiropractic’s] business model has always been profit-based’, whilst his own has been based on public service (7). Such regrettable and misinformed comments do little to advance the debate and the lack of references for his allegations is telling. Some have called for forceful manipulation of the neck to be made illegal, after having observed a rheumatological colleague undertaking the procedure (8). I do not know, of course, what level of training this colleague had received, but in like manner I could call for extraction of wisdom teeth to be outlawed based on having observed a physiotherapist performing the procedure. The safety of chiropractic techniques, particularly spinal manipulation, should rightly be subjected to scrutiny, yet it seems ironic that Ernst characterises it as potentially lethal based on single case reports when he summarily dismisses any potential of benefit demonstrated by a similar level of evidence. There is no doubt that, as with any medical intervention, manipulation of the spine may result in adverse events, some of which may be serious. However, to portray chiropractors as reckless and dangerous is wholly misleading and ignores both the quality of undergraduate training present throughout Europe and the lauded regulation of the chiropractic profession in the UK (9). Readers should not forget that the BCA resorted to legal action only after requests to correct libellous statements were refused. While it has been criticised for its stance, at no time prior to publicising his article did Singh approach the BCA to question its claims; he simply commenced the debate in The Guardian and in so doing defamed the BCA and its reputation. The BCA has no difficulty in accepting the proposal that views and suggestions about the perceived efficacy of healthcare interventions should be permitted in quality peer-reviewed journals. It supports high quality research which objectively informs and evolves the evidence base and would exhort chiropractors to modify their practices where conclusive evidence demonstrates ineffectiveness or a real risk of serious adverse events. Greenhalgh (10) and Thornton (11) summarise the position well in urging authors to be professional and scholarly. Had Singh expressed his argument thus, rather than accusing the BCA of dishonestly promoting bogus treatments for which there was no evidence whatsoever, it is almost certain that this action would never have taken place. 1. Ernst E. Chiropractic for paediatric conditions: substantial evidence? BMJ 2009; 339: b2766 2. Brown R. Chiropractic: clarifying the issues. BMJ 2009; 338: b2782 3. Singh S, Ernst E. Trick or Treatment? Alternative Medicine on Trial (2008) Bantam Press 4. Godlee F. Keep libel laws out of science. BMJ 2009; 339:b2783 5. Gøtzsche PC. Quackery, chiropractic and alternative medicine. BMJ Rapid Responses 2009 14 July. Accessed at www.bmj.com/cgi/eletters/339/jul08_4b2766 6. Colquhoun D. Unprofessional language is appropriate when dealing with unprofessional people. BMJ Rapid Responses. 2009 July 15. Accessed at www.bmj.com/cgi/eletters/339/jul08_4b2783 7. Bartley R. Business Models. BMJ Rapid Responses 2009 July 15. www.bmj.com/cgi/eletters/339/jul08_4b2783 8. Gøtzsche PC. Quackery, chiropractic and alternative medicine. BMJ Rapid Responses 2009 14 July. Accessed at www.bmj.com/cgi/eletters/339/jul08_4b2766 9. Council for Healthcare Regulatory Excellence (2009) Performance Review of Health Professional Regulatory Bodies 2008/09. 10. Greenhalgh T. But was it libel? BMJ Rapid Responses. 2009 July 13. Accessed at www.bmj.com/cgi/eletters/339/jul08_4/b2783 11. Thornton H. Choosing our words carefully. BMJ Rapid Responses 2009 July 13: www.bmj.com/cgi/eletters/339/jul08_4/b2783 Competing interests: Vice President, British Chiropractic Association
Asymmetry in standards of evidence for efficacy and safety 23 July 2009
Michael Power, Clinical author SCHIN, Newcastle upon Tyne, NE1 2ES Send response to journal: Re: Asymmetry in standards of evidence for efficacy and safety	Richard A Brown says in his Rapid response (1) that "..it seems ironic that Ernst characterises it [chiropractic] as potentially lethal based on single case reports when he summarily dismisses any potential of benefit demonstrated by a similar level of evidence". This statement betrays a common misunderstanding about the standard of scientific evidence required for healthcare interventions, be they drugs, surgical operations, or chiropractic. A scientific approach regards a treatment to be ineffective and unsafe until there is good evidence that it is effective and good evidence that the risks are low. There is an asymmetry in the types of evidence regarded as acceptable for showing effectiveness and safety. This asymmetry is reasonable and necessary. Effectiveness, unless the outcomes are truly dramatic and noticable soon after the intervention, should be demonstrated in a randomized controlled trial (RCT) (with patients, their healthcare professionals, and assessors of outcomes blinded as far as possible). The evidence requirements are different for safety. Safety is assessed by the rates of adverse events. Serious adverse events are usually rare. If they were common, they would be easily measured and would outweigh any benefit of the treatment. RCTs (and other clinical trials) are seldom large enough to detect the signal of rare serious adverse events above the noise of more common random events. So, for drugs, surgical operations, and chiropractic, evidence for rare serious adverse events has often to come from case reports and uncontrolled observational studies. This is why the UK monitors for adverse drug events with the "yellow card" scheme and the "black triangle" post-marketing surveillance scheme. Ernst was thus being scientific and not being impartial when he took case reports as evidence on the hazards of chiropractic. (1) Brown RA. Criticism of Chiropractors: No Competing Interests? BMJ Rapid Responses. 2009 July 13. Accessed at http://www.bmj.com/cgi/eletters/339/jul08_4/b2766 Competing interests: None declared
Brown's comment 23 July 2009
E Ernst, Director Complementary Medicine Peninsula Medical School, University of Exeter, 25 Victoria Park Road, Exeter, EX2 4NT Send response to journal: Re: Brown's comment	The vice president of the BCA regrets that I “deconstructed a single sentence of [his] paper and selectively overlooked the main thrust of the article”. What I did was to analyse the evidence he had provided. It would have been fun to deconstruct the rest of his article – but would he have sued me for libel? And by the way, contrary to what Brown states the “competing interests” of my article[1] do mention that I publish the book “Trick or Treatment” with Simon Singh – but thanks for the plug anyway. References (1) Ernst E. Chiropractic for paediatric conditions: substantial evidence? BMJ 2009; 339:b2766. Competing interests: None declared
What is Quackery 23 July 2009
James M May, GP Lambeth Walk Group Practice SE11 6SP Send response to journal: Re: What is Quackery	Richard Brown complains that the current discussion about the evidence for chiropractice has included the use of the term quackery to describe chiropractice. The Wikipedia entry on Qauckery includes this interesting definition, "To avoid semantic problems, quackery could be broadly defined as "anything involving overpromotion in the field of health." This definition would include questionable ideas as well as questionable products and services, regardless of the sincerity of their promoters. In line with this definition, the word "fraud" would be reserved only for situations in which deliberate deception is involved." I would agree that the use of the word is commonly derogatory and should not be part of scholarly discussion. Nevertheless, the burden of disease on vulnerable people has always meant that health is an area wide open to false claims of efficacy - whatever the underlying intention. The flip side of this therefore is that scholarly discussion in a prestigious medical journal should include evidence of efficacy, which seems to be the point in question with regards to the claims of the BCA. Competing interests: Chairman of HealthWatch
Re: Criticism of Chiropractors: No Competing Interests? 23 July 2009
Simon J Baker, Veterinary Surgeon House & Jackson Veterinary Surgeons, Blackmore, Essex, CM4 0LE Send response to journal: Re: Re: Criticism of Chiropractors: No Competing Interests?	Richard Brown has patently read Professor Ernst's commentary (1) on the evidence-base for chiropractic treatment of paediatric non-spinal conditions. I think many observers would probably agree it is now germane for Mr Brown to answer some simple questions with short, pertinent answers. 1. Why did the BCA's "plethora" of evidence not include the well- conducted trials (2, 3, 4) identified by Professor Ernst? I can think of only two answers, so would ask Mr Brown to select one of these binary options: were they unaware of these trials or were they aware of them but withheld mention of them in their "plethora"? Suing for libel was not the only option available to the BCA, but Mr Brown has made public statements on more than one occasion justifying the BCA's resort to a libel suit against Dr Singh. 2. Why did they not choose to publish a rebuttal at the time, given the opportunity reportedly offered by The Guardian? (5) Why has Mr Brown again made no mention of that opportunity? 1. Ernst E. Chiropractic for paediatric conditions: substantial evidence? BMJ 2009; 339: b2766 2. Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O’Shaughnessy D. A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma. N Engl J Med 1998;339:1013-20. 3. Nielsen NH, Bronfort G, Bendix T, Madsen F, Weeke B. Chronic asthma and chiropractic spinal manipulation: a randomized clinical trial. Clin Exper Allergy 1995;25:80-8. 4. Olafsdottir E, Forshei S, Fluge G, Markestad T. Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation. Arch Dis Child 2001;84:138-41 5. Simon Singh "BCA v Singh The Story So Far 3 June 2009". http://www.senseaboutscience.org.uk/index.php/site/project/340 Competing interests: None declared
Response to Brown 23 July 2009
Richard Bartley, Physiotherapist Wales Send response to journal: Re: Response to Brown	There is a fine line between sensible business promotion and over- selling ineffective treatments or actively encouraging unnecessary consultations. I believe most therapists in the UK private sector – chiropractors, osteopaths and non-NHS physiotherapists – practise ethically. However, medico-economic ethics are relatively easier to maintain in state funded health care than in private practice. If physiotherapy was largely a private sector service across the UK, the same temptations that face any private practitioner to oversell their services would apply equally to physiotherapists. My point was that the legal action against Simon Singh could be interpreted – rightly or wrongly – as protecting the financial interests of private practitioners who just happen to be chiropractors. Competing interests: None declared
Reply to Brown 22 July 2009 25 July 2009
Joe Magrath, Retired chemist N/A Send response to journal: Re: Reply to Brown 22 July 2009	Mr. Brown writes "Contrary to Ernst’s assertion that the evidence denying benefit is strong, the reality is that there is a paucity of comprehensive clinical trials ... There is clearly, however, more evidence than ‘not a jot’ [of evidence supporting certain applications of chiropractic.]" The "evidence" provided by chiros was so feeble that anyone knowledgeable about evaluating clinical evidence must conclude that it does not amount to "a jot." For example, there are four papers concerning the treatment of colic, three are execrable in terms of experiment design and cannot be construed as favorable to the practice. The fourth is large and well-designed, and it is negative. By the way, when did the BCA's famous "plethora" of evidence become a "paucity"? Mr. Brown also writes "Some have called for forceful manipulation of the neck to be made illegal, after having observed a rheumatological colleague undertaking the procedure ..." No, there is much more evidence than that for 'chiropractors' causing strokes.(1, 2) While strokes seem to be rare, it is unknown how many victims are uncounted because they left the chiropractor's office and died, or left (and survived) without anyone making the connection. It is only in recent years that neurologists learned to ask stroke victims about recent chiropractic treatment. Furthermore, there is no reliable evidence that the "forceful manipulation" is more beneficial than more conservative treatment. Thus, the risk/benefit calculation results in a very large number (division by zero) mitigating against the chiropractic procedure. Mr. Brown, when you are in a hole, stop digging. 1. http://www.ptjournal.org/cgi/content/full/79/1/50 2. http://stroke.ahajournals.org/cgi/content/full/32/5/1054 Competing interests: Preference for science-based treatments
Do chiropractors treat illnesses or not? 25 July 2009
Peter J Flegg, Consultant Physician Balckpool, UK FY3 8NR Send response to journal: Re: Do chiropractors treat illnesses or not?	I must admit to being confused. Apparently chiropracters do not claim to "treat" illnesses like asthma and colic (only to "help" them), yet they see no contradiction in calling their interventions "treatments". This is something that any layman would infer as indicating active treatment or cure. Perhaps it is time there was legislation in place to prevent the proponents of all alternative medicines and quack remedies from implying their therapies can treat or cure patients, if only to prevent them retreating behind weasel words of legal double speak by bleating: "But I only ever said they could 'help'..." when challenged for the evidence, and resorting to suing anyone who does challenge them. Competing interests: I am a believer in evidence-based medicine.