Bassett Chiropractic Reply

May 29, 2009 at 9:39 pm (Alternative Medicine, Chiropractic) (, , , )

Here is the email I sent requesting further information on the evidence for whiplash, followed by the response from Bassett Chiropractic Clinics (BCC – the have clinics called St Albans Chiropractic Clinic, The Hertford Chiropractic Clinic, Watford Chiropractic Clinic, and Kings Langley Chiropractic Clinic):

Thank you for responding. I would like to concentrate in this email on your claim to help with whiplash injury.

I note that the GCC state in their guidelines (Code of Practice, C1.6)[1] that “[Chiropractors] may publicise their practices or permit another person to do so consistent with the law and the guidance issued by the Advertising Standards Authority.” I wondered if you were aware that the Advertising Standards Authority ruled against BritChiro[2] due to a claim they made to be able to help with whiplash. The ASA stated that they “instructed an independent expert to assess the evidence BritChiro submitted in support of the treatment of whiplash and arthritis. Our expert concluded however that the studies were not sufficient to support efficacy claims for either condition.”

I further note that a review[3] of the evidence for chiropractic and other treatments in treating whiplash associated disorders found that there were no randomised controlled trials for treatment of whiplash with chiropractic. The authors concluded that “Future research should be directed toward clarifying the role of exercise and manipulation in the treatment of WAD” and did not recommend chiropractic as a treatment for whiplash.

I acknowledge your reference to studies by “Forman and Croft , Dan Murphy and Johnny Cook” and I would like further information – please could you pass on the citations for these papers in order that I might read them? I assume the Johnny Cook paper is the 1996 retrospective study that called for randomised controlled trials to be conducted?

Regards,

James.

[1]http://www.gcc-uk.org/files/link_file/COPSOP_Dec05_WEB%28with_glossary%2907Jan09.pdf

[2]http://www.asa.org.uk/asa/adjudications/Public/TF_ADJ_44999.htm

[3]http://www.ncbi.nlm.nih.gov/pubmed/15782244

And now for the Bassett Chiropractic response:

You will, I am sure, realise that whiplash is a colloquial name for a collection of signs and symptoms that usually arise from a motor vehicle accident.In such accidents a number of structures can be involved, including (but not restricted to) joints, muscles, ligaments, tendons and nervous tissue. Most commonly the term whiplash is used where the above-named tissues are sprained or strained. These injuries fall into the category of musculoskeletal or mechanical injuries.

Chiropractors regularly treat neck pain arising from motor vehicle accidents. Having undergone a minimum of four years full-time training, they are qualified to assess, diagnose, manage and treat such injuries. Contrary to popular belief, chiropractic is not a treatment, but a profession which utilises a range of treatment techniques to help its patients. Although chiropractors are highly skilled at spinal manipulation it would be incorrect to assume that every patient is manipulated.[1] Exercise prescription, reassurance, patient education, supervised rehabilitation, massage and mobilisation and spinal rehabilitation are all used to treat whiplash associated disorders (WAD). This approach was suported by the Quebec Task Force Study (see http://www.ciap.health.nsw.gov.au/downloads/specialty/gdl_mngmnt_whiplash.pdf).

You refer to the ASA Code of Practice. You will no doubt have read it thoroughly. The Code explicitly sets out the remit within which it operates. The Code is more concerned with paper advertising and does not extend to material posted on members’ websites.[2] This was the case with the BritChiro case and hence the reason why the ASA got involved. In it, the ASA’s expert is believed to have been Edzard Ernst.

I note that in your email of 19 May you appear to challenge the claim that chiropractic can help in the treatment of headaches. You do not repeat this in your email of 22 May, presumably because you had by then read the ASA adjudication in which event you will have noted that the ASA is satisfied that chiropractic was effective in the treatment of ‘migraine'[3]

I’ve noted three points in their email that I wish to respond to and I have a further couple of requests for them – to provide the citations I asked for seven days ago and comment on the paper I cited in my email to them. Here’s my next email to the BCC:

[1] Thank you for clarifying this point. I’d be interested to learn what proportion of patients are treated with manipulation by Bassett Chiropractic. Is this information available to members of the public?

[2] I find it interesting that rather than defend the claims you have made on your website, you seem to prefer to rely on the ASA’s inability to police websites due to their remit not extending to that medium. Do you consider it acceptable to make claims that are inconsistent with ASA guidance on the basis that it is done so on a website and they therefore are unable to challenge your claims?

The GCC code of practice (C1.6) states that members are allowed to “publicise their practices or permit another person to do so consistent with the law and the guidance issued by the Advertising Standards Authority”. This does not seem to me to mean simply that chiropractors should abide by ASA judgements on paper advertising, but rather seems to indicate that any publicity of a chiropractic practice should be consistent with ASA guidance. Your website is clearly publicising your practice and is certainly not doing so consistent with ASA guidance. It seems to me that you are in breach of the GCC code of practice (as I have interpreted it). Is your interpretation of C1.6 different to mine? I think the GCC should be able to clarify this point and I would suggest that you or I contact them to obtain this clarification.

[3] Actually, I decided it would be better to deal with the conditions separately. “Migraines” and “headaches” are not synonymous (in fact, your website clearly promotes chiropractic for each of these conditions) and I will be requesting the evidence that backs up your claim to be able to help with headaches in a future email.

[4] I note that, despite my request for proper citations of the papers you claimed supported chiropractic for headaches and whiplash, no citations have been forthcoming. If you are relying on these papers to back up your claims to be able to help with headaches and chiropractic then I would expect you to have the papers to hand – or at least be able to pass on the relevant citations within the 6 days since my email.

[5] I also note that you have yet to comment on the systematic review I cited in my previous email. Should I expect comment from you regarding this paper? [http://www.ncbi.nlm.nih.gov/pubmed/15782244]

I will, of course, keep you up to date if and when I receive a further response from BCC. (Ditto the British Chiropractic Association.)

More

The Simon Singh case roundup may be of interest: godknowswhat.wordpress.com; as might the Lay Science post on what chiropractors can’t say.

14 Comments

  1. Michael Gray said,

    At least they responded, unlike Neal’s Yard homeopathetic cowards, who knew when to cut-and-run when their BOGUS mendacious hand was called to public attention.
    (So, sue me you BOGUS succubi!)

  2. jdc325 said,

    I enjoyed the Marcher Lord and Thinking is Dangerous coverage of the Neal’s Yard fiasco. Shame they never responded to the HolfordWatch post, too.

    HolfordWatch,
    Thinking is Dangerous, Marcher Lord. Oh, nearly forgot – smart bombs did it too: Smart Bombs.

  3. Dr. Pat said,

    Headaches / Migraine

    Vectored upper cervical manipulation for chronic sleep bruxism, headache and cervical spine pain in a child. Knutson, G.J Manipulative Physiol Ther Vol 26 No. 6 July/August 2003.

    This is the case of a six-year-old who had chronic sleep bruxism (causing abnormal tooth wear), morning headaches and cervical spine (neck) pain.

    Adjustments to the upper cervical spine using the atlas transverse process as the contact point. There was “complete relief” of her chronic symptoms along with elimination of abnormal joint and structural problems.

    Occipital headaches stemming from the lateral atlanto-axial (C1-2) joint. Aprill C, Axinn MJ, Bogduk N. Cephalalgia 2002 Feb;22(1):15-22
    The lateral atlanto-axial joints (C1-2) are capable of causing pain in the occiput, but few clinical studies have validated this source of occipital headache. Patients presenting with occipital pain underwent diagnostic blocks of their lateral atlanto-axial joints if they demonstrated clinical features presumptively suggestive of a C1-2 origin for their pain. Of 34 patients investigated, 21 obtained complete relief of their headache following diagnostic blocks, indicating that a C1-2 source of occipital pain is not rare. [21/34 = 62%]. The clinical features used to select patients for blocks, however, had a positive predictive value of only 60%.

    A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. Tuchin PJ, Pollard H, Bonello R. Journal of Manipulative and Physiological Therapeutics Feb. 2000:23(2), PP.91-5.

    This was a six month study of 127 migraine sufferers half of whom had diversified chiropractic adjustments. The other half was the control group. Subjects in the manipulation group demonstrated statistically significant improvement in migraine frequency, headache duration, disability and medication use. 22% of those undergoing chiropractic care reported more than 90% reduction in migraines after two months. About 50% reported significant improvement in severity of migraine episodes.

    Evidence report: behavioral and physical treatments for tension type and cervicogenic headache. McCrocy D and Gray R Duke University. 2001.

    This report from Duke University compares the effectiveness of drug and other therapies for the most common type of headache – the cervicogenic headache. The report stated that chiropractic is more effective for headache (both in frequency and severity) than other soft tissue therapies and that chiropractic is superior to drug therapy, providing markedly superior long-term results.

    Encephalgia/Migraine. Bofshever, H. International Chiropractic Pediatric Newsletter Jan/Feb 2000

    A ten year-old girl with chronic, severe migraine (6 times a week for the past 3 years) was unable to go to school due to the severity of her condition. She was treated at a Children’s Hospital by a neurologist.

    Chiropractic examination revealed VSC at C1/C2. The patient’s headaches improved following her 3rd adjustment (one week) at which time she stopped using PeriactinT Syrup (prescribed by her pediatrician). By the third week she was back in school and started dance classes for the first time in 2 years, “and actually began to smile again.” She was leading a normal and healthy life for a child her age by the end of the 5th visit.

    The anatomic basis for the effectiveness of chiropractic spinal manipulation in treating headache. Hack, GD Abstracts from the 15th annual upper cervical spine conference Nov. 21-22, 1998. CRJ, Vol. VI, No. 1, Spring 1999.

    This paper is by the same doctor who led the team that discovered a musculo-ligamentous relationship between the cervical spine (neck) and the dura mater (covering of the brain stem). The author writes:

    An increasing body of literature relates headaches to pathology affecting the cervical spine and a number of clinical trials have demonstrated that chiropractic spinal manipulation directed at the neck is valuable for managing headache.

    Mobilization of the Spine. Grieve GP (1984) Churchill Livingston, London/New York, 4th edition, 22-23.

    All those experienced in manipulation can report numerous examples of migrainous headaches, disequilibrium (vertigo), subjective visual disturbances, feelings of retro-orbital pressure, dysphagia, dysphonia, heaviness of a limb, extra segmental paraesthesia. Restriction of respiratory excursion, abdominal nausea and the cold sciatic leg being relieved by manual or mechanical treatment of the vertebral column.

    Unconventional medicine in the United States, Eisenberg, DM et al., NEJM 28 May 1993. Pp.246-252.

    Twenty-seven percent of Americans who visit alternative health care providers do so for headache relief.

    The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for prophylaxis of migraine headache. Nelson CF, Bronfort G, Evans R, et al. Journal of Manipulative and Physiological Therapeutics, October 1998: Vol. 21, No. 8, pp 511-19.

    This study compared the relative effectiveness of treating migraines with chiropractic care, the anti-depressant/anti-anxiety drug amitriptyline (brand name Elavil); and with a combination of both the drug therapy and chiropractic care.

    Patients who received only chiropractic showed significant improvement, on a par with those given the powerful prescription drug (though without the side effects). The headache index, from a diary kept by each patient, showed chiropractic to have reduced the severity and frequency of headaches as well or better than the combined therapy or amitriptyline alone at each stage of the study.

    Spectrum of pathophysiological disorders in cervicogenic headache and its therapeutic indications. Martelletti P, LaTour D, Giacovazzo M Journal of the Neuromusculoskeletal System 1995; 3:182-7.

    Patients were diagnosed with cervicogenic headache (headache arising from neck structures) and received chiropractic care. The patients reported improvement.

    Chiropractic care of a 13-year-old with headache and neck pain: a case report. Hewitt, EG, Portland, Oregon. Proceedings of the National Conference on Chiropractic and Pediatrics. Oct, 1993 Palm Springs, CA. Pub. International Chiropractors Assoc., Arlington, VA.

    This report describes a 13 year old female who had suffered from severe headaches and neck pain for five days. Following a series of four chiropractic treatments over a two week period, her headache and neck pain resolved.

    Incidence of ponticulus posterior of the atlas in migraine and cervicogenic headache. Wight S, Osborne N, Breen AC. Journal of Manipulative and Physiological Therapeutics, Jan. 1999; vol. 22, no. 1, pp15-20.

    There is a common structural variation of the atlas vertebra called ponticulus posticus (also known as foramen arcuale or “Kimmerle’s anomaly”). Investigators studied the relationship between this condition and headache symptoms in 895 first-time chiropractic patients. The patients had migraine with aura (classical migraine), migraine without aura (common migraine), cervicogenic headache, neck pain only, and other problems. The authors found a significant correlation of ponticulus posticus with migraine without aura. They explain that because the ponticulus posticus is intimately attached to the atlanto-occipital membrane (where the spine and skull meet) and this membrane, in turn, is attached to the dura (the outermost covering of the brain and spinal cord), small tension exerted on the dura may result in excruciating head pain of a type experienced in migraine.

    A case series of migraine changes following a manipulative therapy trial. Tuchin PJ. Australasian Chiropractic & Osteopathy, Nov. 1997; 66(3), pp. 85-91.

    This report discusses four cases of migraine that responded dramatically to chiropractic adjustments. Many self reported symptoms were either eliminated or substantially reduced.

    Average frequency of episodes was reduced by 90% with the length of each headache reduced by 38%. Medication use dropped 94%. Other symptoms associated with migraine were reduced including nausea, vomiting, photophobia and phonophobia.

    Evaluation of the Toftness system of chiropractic adjusting for subjects with chronic back pain, chronic tension headaches, or primary dysmenorrhea. Snyder, BJ, Sanders, GE Chiropractic Technique, 1996;8:3-9.

    This is the study of 24 subjects with chronic back pain, 19 subjects with chronic tension headaches and 26 subjects with dysmenorrhea who underwent a series of Toftness adjustments or sham interventions. Toftness adjustments had significant clinical benefit, whereas those receiving sham interventions did not improve.

    Chronic pediatric migraine-type headaches treated by long-term Inderol prior to chiropractic care, a case report. Haney, VL, Colorado Springs, CO. Proceedings of the National Conference on Chiropractic and Pediatrics. Oct, 1993 Palm Springs, CA. Pub. International Chiropractors Assoc., Arlington, VA

    An 11-year-old pediatric female had an eight year history of severe migraine-type headaches, and a four year history of 20 mg. intake of Inderol daily. The headaches were still incapacitating the child approximately two times per week, despite medication. The child had been a hit and run victim at 18 months, with her first “known” headache occurring at about the age of three.

    Cervical and thoraco-lumbo-pelvic x-rays revealed cervical hypolordosis, C1/C2 hyperextension subluxation and pelvic unleveling. Correction was accomplished using diversified style adjustment. The patient’s initial complaint of severe headaches resolved.

    Follow-up x-rays show that there has been a decrease in thoracic and lumbar curvatures. She has slowly been weaned from Inderol, and is off all pain medications as well.

    The effect of spinal manipulation in the treatment of cervicogenic headache. Nilsson N, Christensen HW, Hartvigsen J. Journal of Manipulative and Physiological Therapeutics, 1997; 20:326-330.

    This is a randomized controlled trial performed at the University of Odense, Denmark by chiropractors and medical doctors.

    Of 53 patients suffering from frequent headaches, 28 received high-velocity, low-amplitude cervical manipulation twice a week for three weeks. The remaining 25 received low-level laser in the upper cervical region and deep friction massage in the lower cervical/upper thoracic region, also twice a week for three weeks.

    The use of analgesics decreased by 36% in the manipulation group, but was unchanged in the soft-tissue group; this difference was statistically significant. The number of headache hours per day decreased by 69% in the manipulation group compared with 37% in the soft-tissue group; this was significant. Finally, the headache intensity per episode decreased by 36% in the manipulation group, compared with 17% in the soft-tissue group; this was significant.

    Spinal manipulation vs. Amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial. Boline PD, Kasaak K, Bronfort G, Nelson C, Anderson AV, Journal of Manipulative and Physiological Therapeutics 1995; 18: 148-154.

    Six weeks of drug therapy were compared to six weeks of chiropractic adjustments. The drug therapy was considered slightly more effective than chiropractic however 82% of the patients had side effects which included drowsiness, weight gain and dry mouth. Cardiac problems and glaucoma were also associated with amitriptyline use.

    Chiropractic patients had no side effects apart from slight neck stiffness in the first two weeks of the study that 5% of the patients reported. After four weeks, chiropractic and drug therapy was halted in both groups. The patients who used drugs began having headaches again while the chiropractic group continued to express headache relief, as well as higher levels of energy and vitality than the drug therapy group.

    A controlled trial of manipulation for migraine. Aust and New Zealand Journal of Medicine 1978;8:589-593. Parker GB, Tupling H, Pryor D.

    Spinal manipulation administered by chiropractors, spinal manipulation administered by medical practitioners and physical therapists and a mobilization procedure administered by physical therapists were studied.

    Eighty-five patients received two manipulations per week over a 2-month period. At the end of the study, all three groups showed clinically significant improvement in the frequency, intensity, and duration of migraine headache episodes.

    Functional disorders (fixations) of the spine in children. Lewit K. Manuelle Therapie, J.A. Barth, Leipzig, 1973. Chap.2.7. Pp.50-54.

    In a total of 57 children’s migraine cases, 48 had excellent results from manipulative therapy. Functional disorders in children may manifest themselves as sleep disorders, loss of appetite, psychic problems or dysmenorrhea and may not exist as spinal pain. Studies on healthy children revealed pelvic subluxations in 40% of all school children, cervical fixation in 15.8%. After manipulative treatments, the problems rarely recurred.

    The effect of manipulation (toggle recoil technique) for headaches with upper cervical joint dysfunction: a pilot study. Whittingham, W, Ellis WB, and Molyneux TP,J Manipulative Physiol Ther, July/August 1994, 17(6): 369-375.

    Twenty-six patients (16 males, 10 females) had chronic headaches with upper cervical joint dysfunction. Significant reduction in the severity and frequency of headaches was reported in a large majority of the subjects (24 out of 26).

    Chiropractic care of a 13 year-old with headache and neck pain: a case report. Hewitt EG. Journal of the Canadian Chiropractic Association, Sept. 1994; 38(3): 160-162.

    Patient had injured her neck in gymnastics. A 13 year-old female suffered from unremitting headache and neck pain for five days. She described them as a throbbing and stabbing pressure that normally occurred once per week and lasted approximately one hour. She had missed one week of school. Her family MD had recommended seeing a chiropractor.

    After four chiropractic treatments over a two-week period, her headache and neck pain resolved.” At a four-week follow-up, she remained pain free.

    Chiropractic care of children with headaches: five case reports. Anderson-Peacock, ED, Journal of Clinical Chiropractic Pediatrics, 1996 1(1) 1996:18-27.

    Five children presented with varying types of headaches to a family-based chiropractic practice. In each case, spinal subluxations were present. Following reduction of those subluxations through chiropractic adjustments the child’s chief complaint remised. Adjunctive therapy (education on diet, posture and exercise) was not given until the headaches stopped. Thus, it was felt that the headache reduction may have been due to the restoration of nervous system function through the chiropractic adjustment.

    Chiropractic treatment of childhood migraine headache: a case study. Proceedings of the National Conference on Chiropractic and Pediatrics 1994, p. 85-90. As abstracted by Masarsky Cs. Headache and Torticollis (Research review) ICA International Review of chiropractic 1995; 51(1): 45-47.

    This is the case of a 10-year-old male with a three-year-history of migraine headaches. During the first month of chiropractic care, it was reported that he only had two prodromal episodes, but no full migraines.

    13-year-old with headache, depression, poor appetite, nausea, general muscular weakness, dizziness and sensitivity to light and noise. Case reports in chiropractic pediatrics. Esch, S. ACA J of Chiropractic December 1988.

    This is the case of a 13-day-old with a history of respiratory difficulty since birth (home birth, uncomplicated). The infant had difficulty nursing due to “stuffiness”.

    Upon presentation patient was in considerable pain, wearing dark glasses and ear plugs to compensate for increased sensitivity to sound and light. One week beforehand he had been injured in a football game collision. Medical doctors had given the child painkillers.

    Patient was hospitalized in traction for two weeks with no improvement.

    Chiropractic examination: X-ray (Davis series) of the cervical spine showed right lateral displacement of atlas with right rotation of C-2.

    Following initial adjustment the patient could ride home without wearing his sunglasses and for the first time in two weeks expressed an interest in food. He returned the next day saying he felt, “The best I’ve felt in six weeks”.

    A holistic approach to severe headache symptoms in a patient unresponsive to regional manual therapy. Stude, DE and Sweere, JJ. Journal of Manipulative and Physiological Therapeutics 1996; 19:202-7.

    This case history deals with a woman who suffered from severe migraine headache symptoms who found no relief from medical care or cervical chiropractic adjustments.

    The patient, suffering from severe headache complaints previously unresponsive to regional cervical spine care, had chiropractic spinal adjustments. After care the patient reported no visits to the emergency room, even after a 1-year follow-up, and the average visual analogue pain decreased.

    Chiropractic treatment of chronic episodic tension type headache in male subjects: a case series analysis. Mootz RD, Dhami MSI, Hess JA, et al. Journal of the Canadian Chiropractic Association, 1994; 38(3): 152-159.

    Ten male outpatients 18-40 years old with a history of chronic headache of at least six months in duration occurring at least once a week were seen in the Palmer College of Chiropractic-West Outpatient clinic.

    Diversified technique was the primary care. Results showed an over 50% decrease in headache frequency and duration. Mean anchored pain scale intensity ratings changed.”

    Headache following whiplash. Kreeft, J. In Spine: State of the art reviews: Cervical Flexion-Extension/Whiplash Injuries, Sept. 1993, p. 395.

    A relationship was noted between whiplash injury and headache.

    Trauma of the cervical spine as cause of chronic headache. Braaf M. & Rosner SJ. Trauma, 1975, 15:441-446.

    A relationship was found between the cervical spine and chronic headache.

    Results of manipulative treatment on childhood migraine. Hippocrates, 1963, pp. 308-316.

    Children with migraine responded well to manipulation.

    Chiropractic management of migraine without aura: a case study. Lenhart, L.J. JNMS 1995: 3(10: 20-26.

    A case of migraine is discussed. The author performed a number of tests to objectify his care. The patient continued his improvement two months post-spinal (cervical) adjustments.

    Mobilization of the cervical spine in chronic headaches. Turk Z. & Ratkolb O. Manuel Medizin, 1987:15-17.

    Spinal manipulation was seen as a successful treatment for headache.

    Spinal curvatures-visceral disturbances in relation thereto. Ussher NT. California and Western Medical Journal, 1933, 38:423.

    Ussher has written that spinal abnormalities could be causing visceral disorders and that X-rays could be a help in diagnosing the spine/internal organ relationship. Ussher urged “A careful neurological examination of the spine” as part of differential diagnosis.

    Spinal manipulation and headaches of cervical origin. Vernon HT. J Manipulative Physiol Ther,1989,12:455-468

    The mechanism of cervical headache was discussed.

    Diagnosis and treatment of TMJ, head, neck and asthmatic symptoms in children. Gillespie BR, Barnes JF, J of Craniomandibular Practice, Oct. 1990, Vol 8, No. 4.

    From the abstract:

    Pathologic strain patterns in the soft tissues can be a primary cause of headaches, neck aches, throat infections, ear infections, sinus congestion, and asthma.

    Manipulative therapy in the chiropractic treatment of headaches: a retrospective and prospective study. Vernon H. J Manipulative Physiol Ther, 1982; 5:109-112.

    Discusses the mechanism of headache and the health of the cervical spine.

    Occipital headaches; statistical results in the treatment of vertebragenous headache. Droz JM, Crot F. Swiss Annals Vlll, 1985; 127-36.

    332 patients received an average of 8.6 chiropractic adjustments. 80% of patients had excellent (pain-free) and good (almost pain-free) outcomes with 10 reporting a 75% decrease in pain.

    Chiropractic adjustment in the management of visceral conditions: a critical appraisal. Jamison JR, McEwen AP, Thomas SJ. J Manipulative Physiol Ther, 1992; 15:171-180.

    This was a survey of chiropractors in Australia. More than 50% of the chiropractors stated that asthma responds to chiropractic adjustments; more than 25% felt that chiropractic adjustments could benefit patients with dysmenorrhea, indigestion, constipation, migraine and sinusitis.

    Chiropractic treatment of chronic episodic tension type headache in male subjects: a case series analysis. Mootz, RD, Dhami MSI, Hess JA, et al. Journal of the Canadian Chiropractic Association, September 1994; 38(3): 152-159.

    Eleven men between the ages of 18 and 40 who suffer from headache received chiropractic care. The patients reported consistent and significant reduction in the frequency and duration of headaches However, the intensity of the headaches in this group was unchanged. The adjustments used were diversified and included myofascial trigger point therapy and moist hot packs. Would another adjusting technique have been more effective? Less effective? Unfortunately that research was not done.

    Toftness Spinal Correction in the treatment of migraine: a case study. Gemmell HA, Jacobson BH and Sutton L Chiropractic Technique, May 1994; 6(2): 57-60.

    Chiropractic success using the light force Toftness technique.

  4. jdc325 said,

    I thank you for your three thousand word comment on the evidence for chiropractic in treating headaches and migraine Dr Pat. I should point out, however, that the subject of the blog post you are commenting on is actually the evidence for chiropractic in treating whiplash. Nonetheless, I will give an overview of the evidence you have posted here.

    Knutson, G.J Manipulative Physiol Ther Vol 26 No. 6 July/August 2003: this appears to be a case report.

    I note that Aprill C, Axinn MJ, Bogduk N. Cephalalgia 2002 Feb;22(1):15-22 was rather a small study (n=34).

    Tuchin PJ, Pollard H, Bonello R. Journal of Manipulative and Physiological Therapeutics Feb. 2000:23(2), PP.91-5 relates to migraine rather than headache – you will of course have noted while reading my blog post that Bassett Chiropractic Clinics claim to treat both headaches and migraine and that I clearly stated that I would be contacting them with regards the evidence for chiropractic for headaches rather than for migraine.

    Evidence report: behavioral and physical treatments for tension type and cervicogenic headache. McCrocy D and Gray R Duke University. 2001: this appears not to be a peer-reviewed study published in a reputable medical journal, but is rather an unsystematic review.

    Encephalgia/Migraine. Bofshever, H. International Chiropractic Pediatric Newsletter Jan/Feb 2000 is another single case report.

    The anatomic basis for the effectiveness of chiropractic spinal manipulation in treating headache. Hack, GD Abstracts from the 15th annual upper cervical spine conference Nov. 21-22, 1998. CRJ, Vol. VI, No. 1, Spring 1999. This appears to be a conference abstract rather than a peer-reviewed study published in a reputable medical journal.

    Mobilization of the Spine. Grieve GP (1984) Churchill Livingston, London/New York, 4th edition, 22-23. This appears to be a book rather than a peer-reviewed study published in a reputable medical journal.

    Unconventional medicine in the United States, Eisenberg, DM et al., NEJM 28 May 1993. Pp.246-252. Your quote from this article reports that “Twenty-seven percent of Americans who visit alternative health care providers do so for headache relief” – not that they go to chiropractors or that the alternative health care they receive is successful.

    The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for prophylaxis of migraine headache. Nelson CF, Bronfort G, Evans R, et al. Journal of Manipulative and Physiological Therapeutics, October 1998: Vol. 21, No. 8, pp 511-19. relates to migraine rather than headache – you will of course have noted while reading my blog post that Bassett Chiropractic Clinics claim to treat both headaches and migraine and that I clearly stated that I would be contacting them with regards the evidence for chiropractic for headaches rather than for migraine.

    Journal of the Neuromusculoskeletal System 1995; 3:182-7. – a statement to the effect that “the patients reported improvement” does not fill me with confidence. Patients receiving an inert treatment often report improvement.

    Proceedings of the National Conference on Chiropractic and Pediatrics. Oct, 1993 Palm Springs
    This is a case report presented at a conference rather than a clinical trial published in a reputable medical journal.

    Journal of Manipulative and Physiological Therapeutics, Jan. 1999; vol. 22, no. 1, pp15-20. says nothing about the effectiveness of chiropractic in headaches or migraine.

    Tuchin PJ. Australasian Chiropractic & Osteopathy, Nov. 1997; 66(3), pp. 85-91. A small study (n=4) relying on self-reported symptoms. Relates to migraine rather than headache – you will of course have noted while reading my blog post that Bassett Chiropractic Clinics claim to treat both headaches and migraine and that I clearly stated that I would be contacting them with regards the evidence for chiropractic for headaches rather than for migraine.

    Snyder, BJ, Sanders, GE Chiropractic Technique, 1996;8:3-9. This is a study of chiropractic for a mixture of conditions – including back pain, headaches, and dysmenorrhea. I am unable to comment further as I cannot find the paper on Pubmed. The search function tells me that “The following term was not found in PubMed: Chiropractic Technique[Jour].” It appears that this journal is not indexed on Pubmed. While being indexed on Pubmed is not a guarantee of quality, it is often a good indication.

    So far I have dealt with the first 1250 of your 3,000+ words and am not inclined to keep trawling through the rest of your comment on the off-chance that there might be some strong evidence for chiropractic in headaches tucked away somewhere in there.

    The evidence you have posted comes from conference presentations, case reports, non-peer-reviewed books, articles published in journals not indexed on Pubmed, articles that do not refer to the effectiveness of chiropractic and as such should be considered irrelevant, rather small clinical trials, self-reported improvements in patients rather than improvements on objective measures, and (repeatedly) studies that refer to migraine rather than headache. I note that you have failed to cite a single systematic review for either migraine or headache. Indeed, “Bandolier could find no systematic review of chiropractic or spinal manipulation for the prophylactic treatment of migraine or headaches, so we carried out a brief review.”. They found that “the evidence that spinal manipulation is better than amitriptyline, or adds to the effects of amitriptyline, is insubstantial”. Link. In another review, Bandolier found that “There is no evidence of specific benefit with chiropractic for headache.”
    Link.

  5. Alan Henness (zeno) said,

    You’d have thought, jdc, that he’d have put his best evidence first…or maybe he was saving the best till last? Oh! The last one was a single case study.

    Thanks for demolishing the ones you did. It all boils down to what chiros consider ‘good’ evidence and I agree with you that single case studies, customer satisfaction surveys and books don’t constitute good evidence. At the heart of that is simply a complete miscomprehension of the effects of bias.

  6. jdc325 said,

    I think that when it comes to evaluating evidence, chiropractors may be unskilled and unaware of it (assuming that Dr Pat is a chiropractor).
    The links that follow are to PDFs: Kruger & Dunning; Ehrlinger et al. I’ve only recently read the latter paper, so not sure I’ve got my head round it fully yet. However, the authors note that: “Part of why the dramatic overestimation demonstrated by poor performers is so fascinating is precisely because they show dramatic overconfidence on tasks about which they have likely received substantial feedback in the past.” This leads me to wonder whether informing chiropractors that the evidence they are citing is of low quality will lead to any change in their behaviour in future. Judging from my email exchanges with chiropractors from the BCA and Bassett Chiropractic Clinics, I am afraid that I must tell you that I think that they will not change their behaviour. They would rather refuse to engage with critics than take a critical look at the evidence they themselves are presenting. (Further email exchange with Bassett is to follow in a new post later today if I get the chance.)

  7. jdc325 said,

    @Dr Pat: for the benefit of casual readers, would you be so kind as to clarify whether you are a proper doctor or a DC (doctor of chiropractic)?

  8. Dr*T said,

    I can’t understand why Dr Pat didn’t just put a link to the original source instead of pretending he/she knew what they were talking about.Didn’t even have the manners to reference it – it IS copyright after all.

    http://www.discoverchiroclinic.com/pages/disease/headache-migraine.htm

    Copyright 2004 Koren Publications, Inc. & Tedd Koren, D.C.

    Seems like a casual driveby rather than a sensible person interested in furthering knowledge.

    T

  9. Dr*T said,

    In fact JDC, for the sake of space, I’d be tempted to delete the post and put a note saying the full blurb can be found at the DiscoverCHiroClinic website.

  10. Blue Wode said,

    For those who may be unaware, that data dump comes courtesy of Tedd Koren, DC, the notorious anti-vaccination chiropractic lecturer, researcher and publisher who lives in Pennsylvania, USA:
    http://www.korenpublications.com/kp/category/vaccine-information

    And the European distributor for his ‘patient education materials’, is none other than UK chiropractor, Richard Lanigan, who operates the following websites:
    http://www.vaccination.co.uk/
    http://www.parkclinic.info/index.htm
    http://chiropracticlive.com/

  11. jdc325 said,

    Thanks for the comments everyone. I had a similar experience fairly recently when someone copied an inaccurate and misleading blog post from elsewhere and pasted it as a comment on one of my blog pages. It turned out the blog post they’d copied from wasn’t even original – the whole thing came from something by the notorious Jack Chick.

    People copying and pasting bullshit all over the internet is a little depressing, frankly. I think I need a Feynman chaser: http://www.youtube.com/watch?v=WT0oyzoR_ik

  12. Chiropractic Refusal to Engage « jdc325’s Weblog said,

    […] recently received a 3,116 word comment from somebody who I can only assume is a chiropractor (”Dr Pat”). According to another […]

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

    […] to what I considered to be an inadequate reply. Further correspondence with them can be seen here and […]

  14. Neil Edwards said,

    Mike Bassett is the best Chiropractor in the UK. and I and many more have trusted him and his expertise for many years.

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