Can you libel woo?

Time to get back in the saddle, and what better way to kick things off than by adding yet another name to the growing list of vexatious would-be libel litigants – and on this occasion it not an Uzbek oligarch or Texas-based shyster but one of the UK’s leading purveyors of woo, the British Chiropractic Association…

Mandrake can disclose that the presenter of the Channel Four series The Code Book is being sued for libel by the British Chiropractic Association.

“It wasn’t a decision taken lightly,” says Dr Antoni Jakubowski, a member of the association’s governing council. “I know that a lot of thought went into this.”

Dr Jakubowski, whose patients have included the golfers Nick Faldo, Ian Woosnam and Justin Rose, adds: “It’s a terrible shame he made those comments and he has been given a full opportunity to take them back. However, he hasn’t.”

The association has taken the unusual step of suing Singh himself rather than the newspaper that published his claims, The Guardian.

One quick correction to make here – where is say ‘Dr Antoni Jakubowski’ is should, strictly speaking, read ‘Dr’ Antoni Jakubowski, given that he’s not an actual medical doctor but a ‘Doctor of Chiropractic’, a qualification that appears to exist only the US and Canada – in the UK there are apparently three Chiropractic colleges that offer ‘Masters degrees’ (Mchiro).

As is now standard practice in such situations, the only polite thing to do is reproduce Singh’s original article in full, which is possible thanks to the kind artifices of Svetlana who did the necessary Google Cache hacking on this occasion, although, on this occasion, the full hat-tip goes to Gimpy for his annotations (also reproduced here), which demonstrate the extent to which Singh’s original article is, for the most part solidly founded on reliable sources and peer-reviewed evidence.

And so, without further ado, I give you Simon Singh’s ‘Beware the Spinal Trap’

This is Chiropractic Awareness Week. So let’s be aware. How about some awareness that may prevent harm and help you make truly informed choices? First, you might be surprised to know that the founder of chiropractic therapy, Daniel David Palmer, wrote that, “99% of all diseases are caused by displaced vertebrae”. In the 1860s, Palmer began to develop his theory that the spine was involved in almost every illness because the spinal cord connects the brain to the rest of the body. Therefore any misalignment could cause a problem in distant parts of the body.

[Gimpy: This claim comes from D.D. Palmer The Science, Art and Philosophy of Chiropractic. Portland, Oregon: Portland Printing House Company, 1910.]

In fact, Palmer’s first chiropractic intervention supposedly cured a man who had been profoundly deaf for 17 years. His second treatment was equally strange, because he claimed that he treated a patient with heart trouble by correcting a displaced vertebra.

[Gimpy: This claim comes from D.D. Palmer The Science, Art and Philosophy of Chiropractic. Portland, Oregon: Portland Printing House Company, 1910.]

[Unity: It’s worth noting that the ‘docorate’ held by Anton Jakubowski originated, as they invariably do, with D.D.Palmer who founded his own ‘School’ of Chiropractic in Iowa in 1897 and shortly, therefore, began ‘graduating’ its own Chiropracters – and the first ever ‘Doctor of Chiropractic was, of course, D.D. Palmer)

You might think that modern chiropractors restrict themselves to treating back problems, but in fact they still possess some quite wacky ideas. The fundamentalists argue that they can cure anything. And even the more moderate chiropractors have ideas above their station. The British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence. This organisation is the respectable face of the chiropractic profession and yet it happily promotes bogus treatments.

[Gimpy: These claims are found in the following documents from the BCA website, Happy Families and A Real Pain in the Back.]

[Unity: Interestingly enough, the BCA’s own Guide for Healthcare Professionals makes no mention whatsoever of treating colic, ear infections, asthma, etc. and sticks rigidly to presenting Chiropractic as a treatment for musculoskeletal problems, particularly back pain – and the same is true of the research cited in this same guide and on the BCA’s website. One might reasonably ask, therefore, why,  if there is evidence that it can be used to treat things like infant colic – as the BCA’s ‘Happy Families’ leaflet claims – the BCA has decline to provide that evidence on its website or make reference to it in its guide for healthcare professionals]

I can confidently label these treatments as bogus because I have co-authored a book about alternative medicine with the world’s first professor of complementary medicine, Edzard Ernst. He learned chiropractic techniques himself and used them as a doctor. This is when he began to see the need for some critical evaluation. Among other projects, he examined the evidence from 70 trials exploring the benefits of chiropractic therapy in conditions unrelated to the back. He found no evidence to suggest that chiropractors could treat any such conditions.

[Gimpy: All details on Ernst’s research on chiropractic can be found on PubMed here. Simon Singh has indeed co-authored a book with Professor Ernst.]

[Unity: A quick search of PubMed yielded two interesting papers on the subject of Chiropractic and Colic – a paper by Olafsdottir, Forshei, Fluge, and Markestad which, as is generally the case whenever woo is subjected to scrutiny by means of a properly constructed randomised blinded and placebo controlled clinical trial, turned up the usual ‘no better than placebo’ result and one by Grunnet-Nilsson and Wiberg which notes that although clinical studies show a no better than placebo outcome there is nevertheless ‘good evidence that taking a colicky infant to a chiropractor will result in fewer reported hours of colic by the parents’ – as a placebo it works best on the parents because remove their sense of helplessness and makes delaing with a colicky infant a bit less stressful in much the same way that toothache is less painful during the daytime when you’ve got things to do to take you mind off the pain.]

But what about chiropractic in the context of treating back problems? Manipulating the spine can cure some problems, but results are mixed. To be fair, conventional approaches, such as physiotherapy, also struggle to treat back problems with any consistency. Nevertheless, conventional therapy is still preferable because of the serious dangers associated with chiropractic.

[Gimpy: This appears to be personal opinion based on research conducted by Ernst & others and is not libellous.]

[Unity: I suspect this to be one of Jakubowski’s main bones of contention – chiropracters trade heavily on the suggestion that what they do is safer than conventional treatments and unlikely to welcome any one pointing out that even they fuck up from time to time and can cause more harm than good.]

In 2001, a systematic review of five studies revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches. These are relatively minor effects, but the frequency is very high, and this has to be weighed against the limited benefit offered by chiropractors.

[Gimpy: This paper can be found here]

[Unity: And the abstract notes, somewhat worryingly that ‘The most valid studies suggest that about half of all patients will experience adverse events after chiropractic SM. These events are usually mild and transient. No reliable data exists about the incidence of serious adverse events. These data indicate that mild and transient adverse events seem to be frequent. Serious adverse events are probably rare but their incidence can only be estimated at present’. So its perfectly safe as long as you don’t bother to count the fuck-ups…]

More worryingly, the hallmark technique of the chiropractor, known as high-velocity, low-amplitude thrust, carries much more significant risks. This involves pushing joints beyond their natural range of motion by applying a short, sharp force. Although this is a safe procedure for most patients, others can suffer dislocations and fractures.

[Gimpy: This is a personal opinion based on evidence]

Worse still, manipulation of the neck can damage the vertebral arteries, which supply blood to the brain. So-called vertebral dissection can ultimately cut off the blood supply, which in turn can lead to a stroke and even death. Because there is usually a delay between the vertebral dissection and the blockage of blood to the brain, the link between chiropractic and strokes went unnoticed for many years. Recently, however, it has been possible to identify cases where spinal manipulation has certainly been the cause of vertebral dissection.

[Gimpy: Some reports here.]

[Unity: And a good general overview of the issue here.]

Laurie Mathiason was a 20-year-old Canadian waitress who visited a chiropractor 21 times between 1997 and 1998 to relieve her low-back pain. On her penultimate visit she complained of stiffness in her neck. That evening she began dropping plates at the restaurant, so she returned to the chiropractor. As the chiropractor manipulated her neck, Mathiason began to cry, her eyes started to roll, she foamed at the mouth and her body began to convulse. She was rushed to hospital, slipped into a coma and died three days later. At the inquest, the coroner declared: “Laurie died of a ruptured vertebral artery, which occurred in association with a chiropractic manipulation of the neck.

[Gimpy: Details of this case and some conclusions here.]

This case is not unique. In Canada alone there have been several other women who have died after receiving chiropractic therapy, and Professor Ernst has identified about 700 cases of serious complications among the medical literature. This should be a major concern for health officials, particularly as under-reporting will mean that the actual number of cases is much higher.

[Gimpy: Details in this paper.]

[Unity: Figures are difficult to come by, but one of more telling statistics I’ve seen was one which indicated that in 2002, malpractice lawsuits relating to strokes caused by chiropratic manipulation accounted for 9% of all claim paid out on by one major provider of chiropractic malpractice insurance.]

Bearing all of this in mind, I will leave you with one message for Chiropractic Awareness Week – if spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.

[Gimpy: Personal opinion based on evidence]

—–

This is going to be one to watch for a number of reasons.

Unusually, the British Chiropractic Association have chosen to sue Singh personally and not the Guardian, which published the article, or both. That may seem to be an odd move, after all newspapers generally tend to make far better targets for defamation suits on purely financial grounds – newspapers can afford the kind of payouts that individual authors would find impossible to meet and if its damages you’re after and you’re confident of a win then suing the press is the best way to maximise your pay-off. On the other hand, the financial position of a national newspaper can be something of a double-edged sword for a would be litigant. Not only can they usually afford to pay top dollar for their legal representation – and money buys quality – but it you take on a newspaper and lose you’re pretty much sure to be picking up the tab for their costs as well as you’re own.

It’s difficult to know quite how to call this – are the BCA suing Singh because they think he won’t be able to risk fighting them all the way to the courtroom for fear of the costs of defending the case, or is it perhaps that they’re running scared of the possible costs (and demands) of taking on the Groan’s legal team and trying to minimise the financial risk of losing the case. Either way it’s a far from confident approach they’re taking although, perhaps, an understandable one given that its difficult to see that they even have as case at all on a reading of Singh’s article.

So far as I can see, the only purpose this current threat of litigation serves is that of getting the Guardian to take the article offline, temporarily, and the question is why is that so important to the BCA given that their claim that Singh’s article is libellous looks at best, extremely thin if not a stone cold loser.

Conceivable, the public kicking that another bunch of woo merchants – homeopaths – has gotten over the last year or so may have spooked the BCA but, casting around for information presents a rather more enticing and plausible explanation as to why they might want to prevent the publication of adverse commentary in the press and any kind of critical public debate surrounding the efficacy and risks of chiropractic…

…and to see that explanation first hand one need only take a short trip over to the website of NICE the National Institute for Clinical Evidence, where we find that one of things they’re working on is a new set of clinical guidelines for the treatement of non-specific lower back pain.

Yep, its the key to the NHS gravy train. If NICE approves the use of chiropractic manipulation as part of the treatment regime for lower back pain then the door opens to chiropractors taking referrals from the NHS under contracts in which the NHS pays their fees and before you can say ‘vested interest’ you’ve got a whole bunch of chiropractors on what is effectively the public payroll. Little wonder then that just about the last thing that the BCA want right now is science journalists asking all sorts of awkward questions like ‘is there any evidence to show that it works?’ and ‘what kind of risks might patients face when referred for a course of woo?’.

I’m speculating, of course, but the idea that this might all be motivated by nothing more than a desire to avoid adverse publicity and awkward question while the door to a taxpayer funded gravy train lies tantalising before them makes about as much sense as an explanation for the threat of legal action against Singh as anything else I can think of…

…its just a shame that no one thought to mention the Streisand Effect to the BCA before they tried it on.