Chiropractic and the BCA Research Page

May 8, 2009 at 9:25 pm (Alternative Medicine, Chiropractic) (, , , , )

The British Chiropractic Association has a Research page on their website. It contains references to “a selection of research papers and reports of relevance and interest”. Let’s take a closer look.

Here’s a rough guide to the make-up of their research page:

Randomised trial BEAM*
Randomised trial Meade**
Randomised trial Meade***
Clinical Guidelines RCGP****
Report Clinical Standards Advisory Group
Report Wiltshire and Bath Health Commission
Guidelines Faculty of Occupational Medicine
Trial Journal of the Neuromusculoskeletal System*****
Guidelines Department of Health
Guidelines NICE
Guidelines EC Research Directorate Council

*Here are Edzard Ernst’s comments on the BEAM trial:

“Three brief comments on the excellent BEAM Trial. My reading of the results is that the data are compatible with a non-specific effect caused by touch: exercise has a significantly positive effect on back pain which can be enhanced by touch. If this “devil’s advocate” view is correct, the effects have little to do with spinal manipulation per se. It would be relevant to know which of the three professional groups (chiropractors, osteopaths, physiotherapists) generated the largest effect size. This might significantly influence the referral pattern. A post-hoc analysis might answer this question. It is regrettable that the study only monitored serious adverse effects. There is compelling data to demonstrate that minor adverse effects occur in about 50% of patients after spinal manipulation. If that is the case, such adverse events might also influence GP’s referrals.” [Link.]

**There is some criticism of this trial here: pubmed/1833493.

***The follow-up trial by Meade et al is discussed here: BMJ and the author of the letter states that:

Unfortunately, their report is far from convincing. The “headline” advantage of chiropractic over hospital management at three years (29%) sounds impressive but refers to an improvement of three points on the 100 point Oswestry scale, or one and a half responses on the questionnaire. This difference may be statistically significant but is clinically trivial.

****The RCGP withdrew those guidelines in 2005 – pdf – it remains to be seen whether these guidelines will be reinstated.

*****I failed to find this journal on Pubmed. According to worldcat.org, it is a journal of the American Chiropractic Association. [Link.]

So, the research page of the British Association of Chiropractors seems to have (as far as I can tell) references to: three randomised trials, one other trial (randomisation not specified), some clinical guidelines (at least one set of which has been withdrawn in 2005 and may or may not reappear), and some reports. This is fine – there’s nothing wrong with making reference to guidelines from bodies such as NICE or the Department of Health. Neither is there anything wrong with referring to randomised trials. The thing is, though, there don’t seem to be any links to systematic reviews.

A systematic review is undertaken in order to “identify, appraise, select and synthesize all high quality research evidence relevant to that question”. The Cochrane Collaboration is a group that aims to improve “healthcare decision-making globally, through systematic reviews of the effects of healthcare interventions”, and their library contains several of these reviews relating to chiropractic.

I have looked at some Cochrane reviews in previous posts on chiropractic and I’ll reproduce that here: This review of 33 trials did not favour manipulation or mobilisation done alone or in combination with various other physical medicine agents. It was unclear if manipulation and mobilisation performed in combination were beneficial, but when compared to one another, neither was superior. [For mechanical neck disorders]

There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.

Overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhoea.

There was weak evidence to support the use of hypnosis, psychotherapy, acupuncture and chiropractic but it was provided in each case by single small trials, some of dubious methodological rigour. Robust randomised trials are required with efficacy, cost-effectiveness and adverse effects carefully monitored.
[For nocturnal enuresis in children. It says there was ‘weak evidence to support the use of chiropractic’ and this was the absolute best I could find on Cochrane for chiropractic – doesn’t exactly fill you with confidence does it?]

Apart from the Cochrane reviews, there are also some reviews on Pubmed. I had a look at a couple. A recent paper, Chiropractic treatment of upper extremity conditions: a systematic review, concluded that:

There is a small amount of chiropractic research into upper limb conditions that is comprised mostly of case studies (level 4 evidence) and a small number of higher-level publications (level 1-3 evidence). Most treatments are multimodal in nature, which address both spinal and peripheral structures, with joint and soft tissue methods. There is a need for future research to be directed at higher-level evidence, in particular, randomized controlled trials for the chiropractic treatment of upper limb conditions. [PMID: 18328941]

Another review, The use of expertise-based randomized controlled trials to assess spinal manipulation and acupuncture for low back pain: a systematic review, had the following in the results and conclusions sections:

Of 12 eligible trials, none made use of an expertise-based randomized trial design […] Investigators designing acupuncture or spinal manipulation trials in which 2 or more active therapies are compared should consider expertise-based randomization to increase the validity and feasibility of their efforts. [PMID:18404113]

There are systematic reviews available. You can read some of them in the form of full-text PDFs for free. I’ve linked to some of these reviews in this blog post. It was easy for me to do so, and it didn’t cost me a penny. This is thanks to the Cochrane Collaboration’s commitment to improve “healthcare decision-making globally, through systematic reviews of the effects of healthcare interventions” – and their decision to make the reviews I have linked to available without charge. Bless ’em. The British Chiropractic Association can add links to these reviews to their research page if they so wish. I won’t even charge them a finder’s fee.

[Thanks are also due to Blue Wode, who pointed out the criticisms of BEAM study and the two Meade et al papers.]

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Chiropractic and the BCA Research Page by jdc is licensed under a Creative Commons Attribution-Non-Commercial-No Derivative Works 2.0 UK: England & Wales License.

14 Comments

  1. apgaylard said,

    For some unknown reason a song from early french lessons at school kept popping into my head while I was reading this:

    Un, deux, trois, j’irai dans les bois,
    Quatre, cinq, six, cueillir des cerises,
    Sept, huit, neuf, dans un panier neuf,
    Dix, onze, douze, elles seront toutes rouges.

    Perhaps it’s some sort of Chiropractic anthem?

  2. jdc325 said,

    Nice. I’d certainly vote for that as the chiropractic anthem.

  3. Simon Singh Case Response Roundup « God knows what… said,

    […] inspired by the trial carried out a critical review of the research mentioned on the BCA’s website. He also wrote to his local MP about the UK libel laws and got a […]

  4. Cargo Cult Science said,

    Good stuff. This will definitely come in handy!

    Shameless blog pimp: http://cargo-cult-science.blogspot.com/2009/05/chiropractors-shot-in-foot.html

    Have chiropractors shot themselves in the foot?

  5. Alt Med Societies « jdc325’s Weblog said,

    […] (perhaps they should have titled it “The Research We Link To Supports Chiropractic”). I blogged this and then contacted the BCA to make sure that they were made aware of some of the systematic […]

  6. BCA Response « jdc325’s Weblog said,

    […] Original post on the BCA research page; my email to the BCA; my follow-up email. […]

  7. Pulsetoday said,

    Prof Edzard Ernst has blogged on chiropractic and the Simon Singh case, asking <a href ="whether chiropractors are destroying their own reputation by promoting chiropractic for conditions where there’s no evidence.

  8. Pulsetoday said,

    Lets try that link again. For prof Ernst’s blog go to http://www.pulsetoday.co.uk/story.asp?sectioncode=20&storycode=4122913&c=1

  9. Martineau chiropractic to check with the BCA « A canna’ change the laws of physics said,

    […] honest incapacity, I am sure, but as jdc’s work shows (here, here, here and finally here), an incapacity nonetheless.  I would also recommend jdc’s helpful […]

  10. Blue Wode said,

    The following comparison of research methods(lifted from the osteopathy-oriented Sacral Musings website)seems to have some relevancy to JDC’s post:

    The Scientific Method of investigation Vs The Chiropractic Method of investigation

    *The Scientific Method of investigation*

    1. Initial Observation of Phenomena

    From an initial observation of a phenomena, A shortcoming in knowledge is identified.

    2. Data acquisition

    Measurement, Observation, Evidence,
    Collect any data that has any bearing on the phenomena under investigation.

    3. Formulate Hypothesis

    Formulate multiple hypotheses that explain the observed phenomena.

    4. Test Hypothesis

    Each hypothesis must be tested against the evidence. Various experiments can be devised to try to disprove and prove each hypothesis.

    5. Reject, Modify or retain Hypothesis

    Any hypothesis that:

    fails to explain the phenomena
    is contradicted by the evidence
    fails experimental scrutiny
    is rejected.

    Contradictory evidence should also be scrutinised to ensure there is a valid contradiction and not just an explainable exception. Supporting evidence should also be scrutinised to ensure the supporting evidence is not just an exception. Experiments are scrutinised for the validity of their results.

    A hypothesis may be refined or modified at any time so that it is consistent with the observed phenomena and the observed evidence.

    A hypothesis that explains the Phenomena and is consistent with the evidence may now be presented as a theory. More than one hypothesis may fulfil both these criteria therefore there can be more than one theory for any one phenomena.

    6. Theory

    The Hypothesis that best fits the observed evidence is presented as the explanation of a phenomena . This is known as a Theory.

    7. Ongoing Testing of theory

    The Theory is published and all interested parties are invited to test the Theory to destruction.

    The theory is used to make predictions. These predictions are tested by experiments or further observations. This is an ongoing process.

    8. Reject, Modify or Retain Theory.

    During testing and investigation, new evidence may come to light that indicates the theory may be incorrect or subject to constraints. The Theory can be either rejected or corrected to make it consistent with all the evidence. Go back to step 7

    *Chiropractic Method of investigation*

    1. Start with a Conclusion

    2. Propose Theory.

    Only theories that support the conclusion should be considered. Little or no attempt should be made to test or disprove the proposed theory.

    3. Collect Supporting Evidence

    One single example of supporting evidence is sufficient, even if there are thousands of examples of evidence that do not support or contradict the theory. Only “supporting” evidence is considered.

    4. Reject Modify or Retain Evidence.

    If the evidence is undeniably proved to be faulty, then reject it and find some evidence that does support the Theory. The Theory is not normally rejected at this point because only one example of supporting evidence is required to justify the theory. Contradictory evidence is ignored.

    If forced to abandon a theory then claim that you didn’t believe it all along and that false Chiropractors proposed it. Propose another Theory that supports your conclusion. Go to step 2

    Golden Rule:- Conclusion is always the same regardless of evidence or the theory.

    Corollary:- For Straight Chiropractors. No evidence at all is required to support a conclusion.

    The Scientific method is designed to discover the truth and eliminate falsehoods, lies, ignorance and misunderstanding.

    The Chiropractic method is self delusional. It can never uncover a falsehood or prove a truth. It only reinforces existing perceptions of the truth.

    The Chiropractic Method is simply Blind Faith and has no bearing on truth whatsoever.

    The scientific method: – base your conclusions on observations/evidence.

    The chiropractic method: – base your observations/evidence on your conclusions.

    See half-way down the page:
    http://www.sacralmusings.com/forum/topics/921165:Topic:25592?x=1&id=921165%3ATopic%3A25592&p age=2

  11. jdc325 said,

    Thanks for that Blue Wode.

  12. Simon Singh and the British Chiropractic Association « Stuff And Nonsense said,

    […] began by looking at the BCA’s research page, noting the research they chose to present and also drawing attention to the research that the BCA […]

  13. Getting Spammed By Mabus « Teaching Science said,

    […] Of course, chiropractors generally (and their ‘professional’ association) have shown a rather poor understanding of research to […]

  14. The British Chiropractic Association: experts in cherry-picking « Stuff And Nonsense said,

    […] May 2009, I wrote about a ‘research’ page on the association’s website and then emailed […]

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