Tag Archives: chiropractic

New evidence gives supporters of chiropractic a headache

The Conversation

Michael Vagg, Deakin University

A paper was published and much discussed online recently, which demonstrates all the problems that I – and other critics – have with the way research is done and interpreted in the world of chiropractic.

The study looked at the effect of chiropractic neck manipulation on people who have migraines.

On the face of it, the article concerned looks like a pretty fair and well conducted study. Despite the methodological difficulties of randomisation and blinding of participants with manual therapies, a genuine effort was made as part of the study design to allow for this.

The trial was a three-armed study comparing chiropractic spinal manipulation (CMST) with a sham manual therapy and a group who continued with their usual care.

Although the deliverers of the manual therapy would know what they were providing, a level of blinding to treatment allocation was possible. It was refreshing to see as well that they had checked to confirm that the blinding of subjects was maintained throughout the study. This is extremely important in assessing the validity of a study, and as the authors point out

The importance of our successful blinding is emphasized by the fact that all previous manual-therapy RCTs on headache lack placebo._

The outcome measures chosen were reasonably fair and representative of the group studied. The statistical analysis was conventional enough. They had performed power calculations using a reasonable comparator, which again increases confidence in the validity of the results and shows they were taking the methodology seriously.

The robustness of the methodology is likely the reason it was included in the European Journal of Neurology – a solid, second-tier journal with a credible reputation.

I would not quibble with the summary of their conclusion, published in the paper’s abstract, that said:

It is possible to conduct a manual-therapy RCT with concealed placebo. The effect of CSMT observed in our study is probably due to a placebo response.

This is the correct scientific interpretation of the data. If it was a drug trial, we would conclude there was no pharmacologically relevant effect within the parameters shown, and it would be considered a negative study.

How very different then is the analysis of the same study by chiropractors. The Chiropractors’ Association of Australia (CAA) mentioned it in their press release titled saying “chiropractors welcome latest evidence of headaches”. The relevant quote is:

A paper published in the European Journal of Neurology in September 2016 was the latest in a series of papers to confirm the effectiveness of chiropractic health care in treating people with migraines. The study of 104 people in Norway found that Migraine symptoms were substantially reduced as a result of chiropractic treatment.

Critical reporting of this study, such as found on the website of the American Council on Science and Health, throws up some interesting conversations and interpretations in the comments section.

While I don’t generally read online comment sections (apart from this column naturally) it’s worth making the effort in this particular case. The author of that piece has made the same basic epidemiological arguments as I have above, and come to the correct conclusion that it is a negative study.

One of the commenters accuses the author of deliberate bias and makes the following piquant observation:

To show how much spin this “article” has the title could have been: Have a Migraine? Skip the meds, sham and Gonstead CSMT both effective. more than medical care.

This commenter appears to be making the same error of interpretation as the CAA. The point of a three-armed study is to differentiate between the effect of any intervention in the study (due to placebo responses) and the improvement due to simply being observed in an artificial situation (known as the Hawthorne effect).

If a treatment is genuinely efficacious, one expects to see three divergent curves with: a minor improvement in the no-intervention group; a larger improvement in the sham intervention group; and a clearly larger improvement in the true intervention group.

A treatment which lacks effectiveness will produce results in which the two intervention groups are indistinguishable. That is exactly what this study returned. Observe the graphs for yourself.

The graphs that tell the story. European Journal of Neurology

Note carefully that the authors of the original study are careful to claim the only conclusion that can be drawn is that it is feasible to conduct a manual therapy study in a single-blinded fashion.

They made no claims about the efficacy of the intervention apart from the fact it was equivalent to sham, and in fact are explicit about the fact they believe the treatment effects were all placebo. Outright claiming the opposite is a new peak of disingenuousness for supporters of chiropractic.

Another characteristic of treatments which do not have efficacy is that the more rigorous the study, the more the claimed effect disappears into the statistical noise. To be definitive about a lack of efficacy, a much larger study would be needed.

The results above would not inspire me to spend a couple of million dollars on a study with 200 people in every arm. Results like this over the years have killed off hundreds of medications which were being developed by Big Pharma.

Academic chiropractors are in the invidious position of trying to establish that an ideologically-based treatment system has a scientific basis. They should be careful what they wish for when conducting rigorous studies, as they may find their fondest beliefs being dashed on the rocks of reality.

The ConversationMichael Vagg, Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist, Deakin University

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

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Is the Chiropractic Board of Australia doing enough to protect consumers from pseudoscience?

The Conversation

Michael Vagg, Barwon Health

In this column two and a half years ago, I took the Chiropractic Board of Australia (CBA) to task for abdicating its responsibility to keep the public safe by waving through questionable activities that some chiropractors have taken part in. It drew this response from the Board, which I thought was a bit lukewarm at the time.

I resolved to wait and see whether they lived up to their public commitment. Maybe they would surprise me with their rigorous approach to protecting the public from the so-called “fringe” elements of the profession. I say “so-called” because some of the views that cause concern emanate from positions of considerable influence with chiropractic ranks.

I have not been the only one with these frustrations. An article by A/Prof Ken Harvey in the MJA Insight publication last year highlights some more direct action he has undertaken in an effort to drag chiropractors kicking and squealing into line with the same professional standards that seem so routine to other groups.

When followed up some months later it is clear little effective action has taken place. More than half of the misleading claims were still present in the complained-of websites. Only one of the ten clinic websites reported to CBA had removed the claims. The misleading and unprofessional claims that the CBA is tasked with regulating are still there, five years after it was first highlighted to them, and seven months after the CBA announced its intention to start getting serious.

The CBA Communique from its June 2015 meeting says:

The Board holds ongoing concerns about advertising by the profession that may be seen as misleading and deceptive. In particular, there have been a number of concerns raised about chiropractors’ advertising that indicates that there may be a lack of understanding of evidence and evidence-based practice.

Worryingly, the CBA’s credibility problem goes beyond advertising regulations. By continuing to lend its gravitas to some of the continuing professional development (CPD) activities that attract approved hours, I would suggest the CBA itself may end up looking like it has problems understanding the concept of evidence-based practice.

Here is an example of an activity approved by the CBA via their delegated authority to the Chiropractors Association of Australia (CAA). It specifically says on the website offering these online modules:

The Paediatric CPD Program is approved in Australia (by the CAA on behalf of AHPRA).

One of the modules on offer in this program is on Craniosacral Therapy. Craniosacral Therapy is an entirely made up and ineffective pseudo-therapy based on what “evidence” exists in the literature. It is implausible and has no credible reason for being promoted as a treatment for anything. To allow practitioners to offer it is entirely inconsistent with a commitment to evidence-based practice.

Here is another howler CBA might rather forget. Obtained by the medical media website 6minutes.com.au, it shows the CAA National approving CPD hours on behalf of CBA for chiropractor Tim O’Shea’s visit to Australia a couple of years ago. Note that CAA specifically pointed out that they were happy for him to use the Board’s imprimatur in his marketing.

CBA subsequently overturned the approval for claimable CPD hours after an investigation prompted by outrage from the more science-based chiropractic community and negative media coverage.

The CBA’s previous inability to professionally manage an investigation of an injured child has not been forgotten either. The failings of that case, including inappropriate public discussion of the highly confidential AHPRA report I have detailed previously.

Just have a look at the slap-downs being handed out by the other AHPRA Boards. Bear in mind also that the chiropractors disciplined by the Board so far have only been disciplined for advertising code breaches. The inappropriate treatment that they actually may be providing, if their advertising is anything to go by, has received little attention.

These ongoing frustrations within the profession have resulted in the formation of a new professional organisation based on professionally progressive ideals. The early signs are positive that this organisation may provide leadership and representation that is more in alignment with what the rest of the scientific health-care community expects from their colleagues in the 21st century. Whether Chiropractic Australia can influence the Board to take a similarly progressive stance against pseudoscience in their profession remains to be seen. It is a daunting and perhaps forlorn task but I wish them well in their efforts.

So after five years of hollow threats and effete regulatory action, the Chiropractic Board of Australia has “written to every chiropractor registered in Australia via the newsletter to remind them what is legal, and what the Board expects” according to the current Chair in a media release. They have also set out at length in their newsletter the standard to which they wish to hold their profession.

I guess it’s just too bad for the public if average chiros treat this latest “campaign” by their supine regulator with the same unresponsiveness they have shown for the last five years. Reform-minded chiropractors might prefer to see a few outrageously unprofessional colleagues temporarily put out of practice pour encourager les autres.

I think when one looks at the efforts of the CBA over the last couple of years, it’s hard to be confident that the public’s interests are being adequately protected. The reluctance of the fractured chiropractic profession to go along with even the most basic self-regulation standards seems intractable with a light touch. The strongest enforcements by the CBA have been brought about by public shaming from the media or within their own profession. As it stands they are the Caspar Milquetoast of regulators.

They could at least have a go.

The ConversationMichael Vagg, Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist, Barwon Health

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

 

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