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Why the recent portrayal of chiropractic is distorted

Richard Brown, vice president of the British Chiropractic Association, responds to the barrage of criticism of the chiropractic profession following its libel action against science writer Simon Singh. He argues the criticism ignores the excellent safety record of chiropractic and the fact that it's a highly regulated profession.

Richard Brown, vice president of the British Chiropractic Association, responds to the barrage of criticism of the chiropractic profession following its libel action against science writer Simon Singh. He argues the criticism ignores the excellent safety record of chiropractic and the fact that it's a highly regulated profession.

I suppose we shouldn't really be surprised.

NICE has issued guidelines on the management of back pain that include spinal manipulation and Professor Edzard Ernst has protested. Despite a development group comprising a range of highly eminent specialists in back pain management, including a past president of the European Spine Society, Ernst's proclamation of committee bias in favour of the manipulative professions has been widely publicised. Seemingly disregarding their fastidious approach to the guideline (the document is 240 pages long with appendices in excess of 400 pages), Ernst has poured scorn on its conclusions and recommendations.

Ernst is no stranger to controversy, yet his latest New Scientist article breaks new ground. In it, he systematically takes apart the chiropractic profession with a series of inaccuracies and misinformed comment. For one who claims to be a scientific researcher, there is a surprising lack of original clinical trials conducted by his Exeter-based department. Instead, he focuses on so-called systematic reviews (including the bizarrely titled systematic review of systematic reviews) looking at available research and publishing what he claims is the consensus.

All very laudable, you may think. To educate the medical community and the public of the merits (or otherwise) of complementary medicine surely must be a force for good. Until, that is, one discovers that Ernst seems to ignore material that does not support his agenda.

Repeatedly, Ernst has spoken out on what he perceives to be the dangers of what he disrespectfully calls ‘chiropractic therapy'. Ernst widely disseminates his view that chiropractic can cause stroke and death, despite strong evidence to show that undergoing spinal manipulation from a chiropractor or osteopath is no more dangerous than visiting a GP.

In the wake of two groundbreaking studies published in the last two years demonstrating the safety of chiropractic care, Ernst continues to peddle his scaremongering to a susceptible public. He cannot claim not to have been aware of these studies – he was consulted on the methodology of one of them and commented positively on its conclusions – yet chooses to ignore them when warning the public against consulting chiropractors. Hardly the actions of a scientific researcher committed to finding out the truth without fear or favour.

Ernst fails to acknowledge at any point in his New Scientist article that chiropractic is regulated by statute and that patients are protected by a strict Code of Practice and Standard of Proficiency. As one of the nine UK regulated healthcare professions, the General Chiropractic Council is overseen by the Council for Healthcare Regulatory Excellence (CHRE). In its most recent report, the CHRE commented, "[The GCC] takes its role seriously and aspires to, and often maintains, excellence."

Although he grudgingly admits that spinal manipulation might be useful for some types of back pain, Ernst is at pains to portray chiropractic as ‘pre-scientific' and lacking any credible evidence to support its claims. He points to a paucity of randomised controlled trials to justify this lack of evidence. As well as overlooking the fact that a very sizable number of accepted medical interventions have little or no research evidence to support them, Ernst seems to have forgotten that practising evidence-based care comprises far more than rigid adherence to clinical research. He gives no credence to the value of individual clinical experience and expertise and in doing so, overlooks completely the experiences in practice that stimulate more rigorous scientific enquiry and contribute to the knowledge base.

In his castigation of the chiropractic profession, Ernst makes a further cardinal error. Instead of engaging in meaningful dialogue with the chiropractic profession and seeking to truly understand its contribution to the health of the nation, Ernst has repeatedly shied away from invitations to participate in debate and visit the educational institutions. In doing so he has preferred to repeatedly proffer his misguided assumption that chiropractic treatment is synonymous with spinal manipulation. That he refers to it simply as therapy further suggests a blatant misapprehension that chiropractors indiscriminately crack the spines of all who walk through their doors.

Just as medicines are but one component of medical care, so spinal manipulation is a tool used as part of a package of care by chiropractors. Both approaches may have side effects, but in keeping with responsible healthcare a careful risk-benefit analysis must be undertaken. Where manipulation is contraindicated, other treatment options exist. Chiropractors are trained to utilise a range of treatment techniques including advice, reassurance and exercise and do so every day in their practices.

But let's get to the real agenda behind Ernst's New Scientist article. Since 2008, the co-author of his book Trick or Treatment? Alternative Medicine on Trial Simon Singh has been embroiled in a libel case after labelling treatment for certain conditions promoted by the British Chiropractic Association (BCA) as ‘bogus' and having ‘not a jot of evidence' to support them.

At a hearing in the High Court in May, Mr Justice Eady ruled that the meaning of the words used by Singh was that the BCA knowingly and dishonestly promoted quack remedies for which no evidence whatsoever existed.

The case has sparked a vicious backlash from Singh's supporters who, predictably, have called for reform of the English libel law. Claiming that the BCA has sought to ‘stifle scientific endeavour', pro-Singh professional and lay scientists have mounted a nationwide campaign of intimidation against chiropractors and via widespread blogging have encouraged a ‘blitzkrieg' against the BCA.

As Ernst, Singh and their band of supporters continue to wage war on the chiropractic profession, consider this: each year tens of thousands of patients benefit from chiropractic. Its safety record is equal or superior to any other regulated health profession in the UK and there have been no known deaths from chiropractic treatment that have occurred in the UK. Patient satisfaction is consistently high and the profession is committed to researching their methods of treatment to deliver ever greater standards of care. The NICE guidelines, showing both clinical and cost benefit of chiropractic management, are testament to these advances and for the first time there is a realistic prospect of NHS-funded chiropractic.

Not bad for mumbo-jumbo gobbledygook.

Richard Brown, vice president of the British Chiropractic Association

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