What alternative health

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The UK regulatory body, the General Chiropractic Council (GCC), frequently expresses the view that those involved in National Health Service (NHS) healthcare commissioning should fund chiropractic care. The following links may be helpful to NHS healthcare commissioners, and others, in reaching an informed decision regarding chiropractic in the UK.   NOTE: Section S3.2 of the GCC's Code of Practice and Standard of Proficiency (effective from 30th June 2010) requires that the care selected and provided by chiropractors ""must be informed by the best available evidence"" and minimise risks to the patient.


Related links


Beware the spinal trap

The Meade Report criticism

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The British Chiropractic Association: aligning itself with UK fundamentalist chiropractors?

The concept of pursuing prescribing rights for chiropractors came about as a result of the 2002 UK Health and Social Care Act, which permitted professions allied to medicine, including chiropractic, to attain rights for limited prescribing. As a consequence, in 2009, following a vote by British Chiropractic Association (BCA) members at its AGM in 2008, the BCA undertook a postal ballot of its members to determine whether there was support for pursuing these rights, the results of which were announced on the opening day of Richard Brown's presidency. Two thirds of those eligible to vote chose not to express a view, but of those who did nearly 80% supported a proposal to further explore prescribing rights for UK chiropractors.

On the 1st September 2009 the Council of the British Chiropractic Association approached the UK chiropractic regulatory body, the General Chiropractic Council (GCC), to ask it to consider making an application to the Medicine and Healthcare Products Regulatory Agency (MHRA - part of the UK Department of Health) for limited prescribing rights for UK chiropractors. However, following some reflection and a change of opinion by Richard Brown (after continued criticism from quarters of the profession for whom the concept of drug prescription was an anathema), the BCA Council reconsidered its views at a meeting on 20th February 2013 (even although, four years on, the matter had yet to be considered by the GCC). The meeting saw the BCA Council unanimously deciding to support Richard Brown's new stance. Richard Brown explained that, whilst there were some benefits in acquiring limited prescribing rights (which the BCA welcomed as recently as July 2012), there were major issues of regulation, practicality and competence that would need to be overcome, and he believed that the BCA and its members should continue to strive to position chiropractic "in its role as the non-surgical experts in the treatment of MSK (musculoskeletal) conditions". In support of his U-turn, Richard Brown cited the New Zealand Commission of Inquiry's 1979 report, Chiropractic in New Zealand:

"25. As we have seen, much is made by chiropractors of the drugless and non-surgical nature of their therapy. But modern chiropractors do not suggest that there is only one cause of disease; they admit there are limits to their expertise; and they acknowledge the need for medical intervention and medical monitoring. They do, however, place emphasis on the body's natural functioning and its natural recuperative powers.

26. In these matters of emphasis we see some value in the contribution that the chiropractic outlook can make to healthcare generally. There cannot be any fundamental objection to an attitude to healthcare which restricts drugs to cases where they are shown to be a matter of necessity rather than a matter of mere convenience. Nor can it seriously be suggested that anyone is unreasonable to believe that it is better for the body's disorders to be relieved if possible, by natural rather than artificial or chemical means."

At a closed meeting on the 8th August 2013, the GCC finally considered the BCA's 2009 request that it approach the MHRA seeking limited prescribing rights for chiropractors. All four UK associations had submitted their thoughts on the issue, three of whom had been against seeking limited prescribing rights from the start. The GCC decided that to endorse or lead the call for limited prescribing rights for chiropractors was not the role of the regulator, and concluded that any application to the Department of Health must come from the profession as represented by the associations. In the end, the subluxation-based (vitalistic) Alliance of UK Chiropractors (AUKC), composed of the Scottish Chiropractic Association, the United Chiropractic Association, and the McTimoney Chiropractic Association, who claim to represent the majority of chiropractors in the UK, admitted on the 2nd September 2013 to playing a key role in blocking the BCA's original 2009 application.  Click here and here to learn more about the AUKC. 

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"Some national [UK] and international guidelines advise physicians to use spinal manipulation for patients suffering from acute (and chronic) low back pain. Many experts have been concerned about the validity of this advice. Now an up-date of the Cochrane review on this subject seems to provide clarity on this rather important matter....The authors draw the following conclusion: "SMT is no more effective for acute low back pain than inert interventions, sham SMT or as adjunct therapy. SMT also seems to be no better than other recommended therapies"...In other words, guidelines that recommend SMT for acute low back pain are not based on the current best evidence. But perhaps the situation is different for chronic low back pain? The current Cochrane review of 26 RCTs is equally negative: "High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain"...This clearly begs the question why many of the current guidelines seem to mislead us. I am not sure I know the answer to this one; however I suspect that the panels writing the guidelines might have been dominated by chiropractors and osteopaths or their supporters who have not exactly made a name for themselves for being impartial. Whatever the reason, I think it is time for a re-think and for up-dating guidelines which are out of date and misleading. Similarly, it might be time to question for what conditions chiropractors and osteopaths, the two professions who use spinal manipulation/mobilisation most, do actually offer anything of real value at all. Back pain and SMT are clearly their domains; if it turns out that SMT is not evidence-based for back pain, what is left? There is no good evidence for anything else, as far as I can see. To make matters worse, there are quite undeniable risks associated with SMT. The conclusion of such considerations is, I fear, obvious: the value of and need for these two professions should be re-assessed." Edzard Ernst (29th April 2013)

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A close look at how the BCA [British Chiropractic Association] appears to defend the business interests of its members by instructing them not to share with the media, public, or patients information revealing its views on the evidence for the efficacy of chiropractic and its safety. Zeno's blog (8th April 2013)

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The [British Chiropractic Association's] "strictly confidential" message is intriguing in several more ways...I find the most remarkable aspect that the BCA seems to attempt to silence its own members regarding the controversy about the value of their treatments. Instead they proscribe answers (should I say doctrines?) of highly debatable accuracy for them, almost as though chiropractors were unable to speak for themselves. To me, this smells of cult-like behaviour, and is by no means indicative of a mature profession – despite their affirmations to the contrary." Edzard Ernst's blog (8th April 2013)

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A few weeks ago, The College of Chiropractors, a Company Limited by guarantee, was given a royal charter...From my perspective, this begs numerous questions; here are just some of them: 1) Have UK chiropractors truly been promoting "high practice standards and certifying quality and thus securing public confidence"?  I would argue that they have been doing the opposite. They made bogus therapeutic claims by the hundreds on their websites, and when Simon Singh had the courage to make this public, they sued him for libel. Call me old-fashioned, but I fail to see how this maintains "the highest possible standards of chiropractic practice for the benefit of patients" nor how this might "promote the art, science and practice of chiropractic."  2) Is it truly for the benefit of the people that so many chiropractors deny the considerable risks of spinal manipulation? I would have thought that this is a serious disservice to the people and the health of the nation and believe it reflects an irresponsible disregard of the precautionary principle in health care.  3) How can we accord the high aims of the College with the fact that UK chiropractors demonstrably violate fundamental rules of medical ethics, e.g. informed consent, and that their professional bodies must be aware of this fact, yet have so far failed to do anything about it? I think there is a discrepancy here that needs explaining. 4) Does the College truly "advance the study of and research in chiropractic?" We have shown that UK research into chiropractic has not increased but decreased since statutory regulation. This leads me to suspect that regulation is being abused as a means of gaining recognition and not as a mechanism to protect the public.  Considering all this, I find that the status of the other Royal Colleges has been de-valued by the ascent of this organisation."   Edzard Ernst (1st March 2013)

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"The UK General Chiropractic Council has commissioned a survey of chiropractic patients' views of chiropractic...Perhaps the most remarkable finding from the report is the unwillingness of chiropractors to co-operate with the GCC which, after all, is their regulating body. To recruit only ~10% of all UK chiropractors is more than disappointing. This low response rate will inevitably impact on the validity of the results and the conclusions.  It can be assumed that those practitioners who did volunteer are a self-selected sample and thus not representative of the UK chiropractic profession; they might be especially good, correct or obedient. This, in turn, also applies to the sample of patients recruited for this research. If that is so, the picture that emerged from the survey is likely to be far too positive.  In any case, with a response rate of only ~10%, any survey is next to useless. I would therefore put it in the category of 'not worth the paper it is printed on'."  Professor Edzard Ernst (15th February 2013)

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This overview by the Vice President of the British Chiropractic Association, Matthew Bennett, reveals that, in the UK, “much of the early work” on the statutory regulation of chiropractors was done at dinner parties attended by HRH Prince Charles, among others. (20th December 2012)

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“The College of Chiropractors has, indeed, been granted a Royal Charter, but it's a Royal Charter of Incorporation, granted by the Privy Council, with Nick Clegg as Lord President…The College claims it "currently has more than 1500 UK members and 2800 members worldwide." That adds up to just 4,300 members (with only 1,500 in the UK), somewhat short of the requisite 5,000. Or does that 2,800 include its 1,500 UK members? In which case, it's even further off meeting the 5,000 requirement. But why only 1,500 members in the UK? There are 3,374 chiropractors registered with the General Chiropractic Council, so the College of Chiropractors doesn't even represent half of the chiropractors in the UK. Is this further evidence to the split between the different chiro factions?...The grant of the Royal Charter on 7th November followed a letter of support from Department of Health dated 26th September 2012 to the President of the College to say the Department would be advising the Privy Council that the College’s charter application should be taken out of abeyance. So, despite the College failing to meet the requirements set out by the Privy Council, it was interference in that process by the DoH that produced the Royal Charter a mere weeks later. Once we have that letter, we'll let you know what it says. Meddling, anyone?” Zeno’s blog (26th November 2012)

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“Critics of complementary and alternative medicine have condemned the Privy Council's decision to award a Royal Charter to the chiropractors' professional body. According to the website of the British Chiropractic Association (BCA), the College of Chiropractors was granted the charter by the Queen last week, following a meeting of the Privy Council…Edzard Ernst, emeritus professor of complementary medicine at the University of Exeter, described the awarding of the charter as "a serious mistake which debases the [royal] title as carried by all the other royal colleges"…David Colquhoun, professor of pharmacology at University College London, described the awarding of the Royal Charter as "a bad day for reason”.” Times Higher Education Supplement (16th November 2012)

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“…like many authorities, the Privy Council has been fooled and cajoled. In addition to this Royal seal of approval giving legitimacy to a nonsense therapy, it also undermines the credibility of the other medical Royal Colleges. Members of these colleges may wish to express their disapproval.” Andy Lewis, Quackometer blog (13th November 2012)

(See the two links immediately below for more background.)

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“A new analysis of the evidence has just been published, and, in view of the news just out of a Royal Charter for the UK College of Chiropractors, it is time to dedicate some real attention to this important issue…I find many of the statements of the authors helpful and commendable, particularly considering that they are chiropractors. They seem to be aware that, when there is genuine uncertainty, we ought to err on the safe side [the precautionary principle]. Crucially, they comment on the practical implications of our existing knowledge: “Considering this uncertainty, informed consent is warranted for cervical spinal manipulative therapy that advises patients of a possible increase in the risk of a rare form of stroke…” A little later, in their discussion they write: “As the possibility of an association between cervical spinal manipulative therapy and vascular accidents cannot be ruled out, practitioners of cervical spinal manipulative therapy are obliged to take all reasonable steps that aim to minimise the potential risk of stroke. There is evidence that cervical rotation places greater stresses on vertebral arteries than other movements such as lateral flexion, and so it would seem wise to avoid techniques that involve full rotation of the head.” At this point it is, I think, important to note that UK chiropractors tend not to obtain informed consent from their patients. This is, of course, a grave breach of medical ethics. It becomes even graver, when we consider that the GCC seems to do nothing about it, even though it has been known for many years. Is this profession really worthy of a Royal Charter? This and the other question raised here require some serious consideration and discussion which, no doubt, will follow this short post.” EdzardErnst.com (13th November 2012)

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“We all remember the libel case of the British Chiropractic Association (BCA) against Simon Singh, I’m sure. The BCA lost, and the chiropractic profession was left in disarray. One would have thought that chiropractors have learnt a lesson from this experience which, after all, resulted in a third of all UK chiropractors facing disciplinary proceedings. One would have thought that chiropractors had enough of their attempts to pursue others when, in fact, they themselves were clearly in the wrong. One would have thought that chiropractors would eventually focus on providing us with some sound evidence about their treatments. One would have thought that chiropractors might now try to get their act together. Yet it seems that such hopes are being sorely disappointed. In particular, chiropractors continue to attack those who have the courage to publicly criticise them. The proof for this statement is that, during the last few months, chiropractors took direct or indirect actions against me on three different occasions…” EdzardErnst.com (17th October 2012)

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Professor Edzard Ernst delivers his talk ‘After the Storm’ to the 2012 International Skeptics Conference in Munich. He highlights concerns raised by the British Chiropractic Association’s unsuccessful attempt to sue the writer and broadcaster, Simon Singh, for libel. The talk is preceded by Professor Ernst’s acceptance of the Committee for Scientific Investigation’s ‘In Praise of Reason’ award. (May 2012)

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"While we acknowledge that there is uncertainty surrounding the causality of the association between manipulation and these events, we do not accept that the same uncertainty exists regarding the benefits…

The British Chiropractic Association has suggested that we have cherry picked low quality evidence. We believe that we have considered the key studies, but if the BCA are aware of important or more robust contradictory evidence then we would be very happy to consider it…

Dr Mann suggests that the UK BEAM trial provides evidence for the effectiveness of cervical manipulation, but since it was a trial of treatment for low back pain, this assertion is tenuous. However it is worth discussing this study as it highlights a number of important issues for manual therapists wishing to use high quality evidence rather than anecdote to inform their management of patients with neck pain. Firstly, the differences reported for the primary outcome measures were lower than the authors pre-set minimal clinically important difference. In addition, as is common to many trials of manual therapy for neck pain, the therapist, patients and the assessors were not blinded. It is likely that the already small effect sizes seen are exaggerated by the resulting biases. Most significantly in relation to the current discussion on high velocity manipulation techniques, it is important to recognise that clinicians were able to choose from a range of manual therapy techniques as well as mobilising and strengthening exercises. As is the case in many neck pain trials, effectiveness of a package of care provided by a manual therapist cannot be used to specifically endorse high velocity thrust manipulations, as they are often only part of a treatment package. It should also be noted that this package of care was designed and endorsed by the professional bodies representing osteopathy, chiropractic and physiotherapy in the UK and explicitly excluded the use of high velocity thrust techniques to the neck because of the chance of serious side effects. We also do not accept that the existing data on risks, imperfect though it is, is uninformative. The fact that not all studies have shown an effect in the over 45's most likely reflects the other causes of these events in that population clouding the picture. Indeed finding the association in a group who would not normally be expected to experience such an event (i.e. <45 yrs) arguably makes the association more convincing. While attempts to develop screening procedures is commendable, given that the association between manipulation and VAD/stroke is found in this group who are less likely to present with key vascular risk factors, it seems unlikely that screening will achieve its goal satisfactorily.

Reid and colleagues point out that in one survey [3], 45% of these events may have been preventable, which still leaves a rather uncomfortable 55% that may not have been. Indeed acceptance of Cassidy and colleagues argument, that there are patients receiving cervical manipulation who present with a pre-existing dissection, only further illustrates that screening is far short of being effective. We would suggest that comparisons with NSAIDs or surgical procedures are less useful. Beyond the issue of inadequate data for drawing fair comparisons and the likely underestimation of the true risks for manipulation, manual therapists might more simply ask how their own practice may be made safer

…in possession of truly informed consent, why would one choose a technique that confers no unique benefit but poses a possible unique risk?

...In the end, it remains our opinion that cervical spinal manipulation is unnecessary and inadvisable given the other options available."

Neil O'Connell et al, British Medical Journal (27th June 2012)

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"Neurologists have been warning for years of growing evidence that neck manipulation carries a risk of stroke and death from trauma to the neck arteries. Chiropractors have generally denied or minimized this risk. A recent article in the BMJ (British Medical Journal) reviews this controversy and concludes that neck manipulation, based upon relative risk vs benefit, should be abandoned as a therapy…A number of recent systematic reviews of spinal manipulation in general (but including neck manipulation for headaches) have concluded that there is no evidence to support that they are effective for any indication. Looking specifically at cervical manipulation for headaches, systematic reviews are also negative. The reviews indicate that the best controlled studies are negative. The less rigorous studies are mixed. This is a familiar pattern, consistent with an ineffective treatment combined with researcher and publication bias. The BMJ article is actually more favorable, concluding that there is evidence for short term symptomatic benefit from cervical manipulation. However, the evidence shows that the benefits are no better than safer treatments, such as massage, medication, or neck mobilization (a gentler intervention favored by physical therapists)…That is a devastating assessment of any medical intervention, and certainly justifies abandoning that method…Some critics of neck manipulation argue that it should not be abandoned completely but should be reserved for highly selective cases in which there is no contraindication and the safer treatments have been tried and found to be ineffective. This too is reasonable, but is still based upon the notion that neck manipulation has a significant benefit, which has not been established by rigorous clinical evidence. The response of the chiropractic community so far has been predictable. The British Chiropractic Association is quoted by the BBC:

"The cherry-picking of poor quality research needlessly raises alarm in patients and does little to help the people suffering from neck pain and headaches to choose the most appropriate treatment."

As is typical of CAM apologists, they are begging the question - does neck manipulation help those suffering from neck pain? The answer, in my opinion and based on published systematic reviews (the very antithesis of cherry picking) is no. Further, claiming that a reasonable and thorough assessment of risk vs benefit is needlessly alarmist says volumes about the approach of the chiropractic community to their own practice and the scientific evidence. My primary criticism of the CAM community in general, and the chiropractic profession specifically, is that they do not have a culture and philosophy of ethical science-based practice. If they did they would be practicing real medicine, not the "alternative." The issue of neck manipulation and risk of arterial dissection reflects this basic reality, and is not an isolated case but a systemic problem."

Steven Novella, MD, James Randi Educational Foundation's Senior Fellow and Director of the James Randi Educational Foundation’s Science-Based Medicine project. (9th June 2012)

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“The British Chiropractic Association have an article on their website that contains a rather interesting comment regarding this BMJ article. While the BCA are happy to refer to “one report of 24 cases” and “one UK study” to support two of the various claims they make during the piece, they finish the article by complaining about the BMJ article:

"The cherry-picking of poor quality research needlessly raises alarm in patients and does little to help the people suffering from neck pain and headaches to choose the most appropriate treatment.

If you have any concerns about your treatment, please discuss this with your chiropractor."

That’s right – the BCA have complained about somebody other than them cherry-picking poor quality research. And why wouldn’t they? Cherry-picking poor quality research is very much their territory and they presumably do not like others trespassing…In May 2009, I wrote about a ‘research’ page on the association’s website and then emailed the BCA. In the BCA’s own words, this page contained “a selection of research papers and reports of relevance and interest”. A selection. The BCA had selected certain research papers and reports. Entirely coincidentally, these papers and reports were positive with regard to chiropractic treatment. So, the research published by the BCA was variable, made up of reports, guidelines, and a small number of RCTs. All systematic reviews and meta analyses were omitted. It doesn’t look to me like the BCA selected their research by looking for the best available evidence…” Stuff and Nonsense blogspot (8th June 2012)

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Summary: “Our interest lies in the regulation of chiropractors and osteopaths because of the lack of a robust evidence base for chiropractic and osteopathic spinal manipulation. Statutory regulation rightly confers respectability and trustworthiness in the eyes of the public and these need to be protected to maintain that trust. For chiropractic and osteopathy, we do not believe statutory regulation is deserved or necessary and it gives a false imprimatur that misleads the public. Because of this, our overall view is that statutory regulation of chiropractors and osteopaths is not appropriate and recommend that this statutory regulation be abolished. We believe that adequate protection of the public can be achieved by existing regulations (such as The Consumer Protection from Unfair Trading Regulations 2008) as are applied to any other alternative therapies and businesses. However, we appreciate that this may not fall within the scope of the present consultation and we offer our responses regardless. We are concerned that some of the claims made by these practitioners are not founded in robust evidence and that they can therefore mislead. We are concerned that current statutory regulation is failing by not adequately protecting the public from such claims. We are aware that the situation regarding claims made on practitioners’ websites has significantly improved in the past three years, but we believe that much more still needs to be done and that the current regulatory framework is not fit for purpose in this regard. The Law Commissioners’ consultation on the reform of the legislation is a welcome opportunity to greatly improve the protection of the public and we hope that the Law Commissioners will note and act on our recommendations. We therefore restrict our views to those proposals and questions that directly affect the regulation of chiropractors and osteopaths and we make recommendations that we believe will enhance public protection.” (31st May 2012) [pdf]

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“A quick email to the UCL authorities quickly determined that the claimed endorsement was not true. Attempting to access this page now leads to “page not found". The page vanished on Sunday 22nd April, and a near identical page for the Broadgate Pine and Joint Clinic had already vanished on Friday 20th April. While it is true that two surgeons from UCL’s Institute of Sports Medicine have worked in the same building, they neither use chiropractic nor endorse it. I’m assured that the alleged endorsement never happened. London Chiropractors won’t say where it came from. It seems that it was simply made up. I think that’s called a lie. I presume it is a sign of the desperation of chiropractors.” Professor David Colquhoun, DC Science (23rd April 2012)

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“Who will regulate the chiropractic claims made at the Olympics?... What evidence is there that chiropractic manipulation can either prevent or treat sports injuries? Not a lot, as you might guess.” Lecanardnoir, Quackometer blogspot (16th April 2012)

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“It would appear that the device appeals to chiropractors as it gives a scientific veneer to an unvalidated diagnostic. On the basis of the scan, a customer might be enrolled on a lengthy and expensive course of treatment that is both ineffective and unnecessary, but very profitable to the chiropractor…Remarkably, it looks like it is common practice for chiropractors in the UK to use some sort of discount incentive and questionable diagnostic procedure to rope customers into ‘wellness’ treatment plans…Chiropractic is a statutory regulated profession. As such, it would appear remarkable that chiropractors could get away with such practices…But if they were to stamp out dodgy practices, I would guess that there would be few chiropractors who could sustain a business. Would a regulator regulate itself out of business? If its only goal was to protect the public then is should and it could. But if it is really only protecting its own existence, then do not expect to see any action here.” Lecanardnoir, Quackometer blogspot (14th April 2012)